As you know, the demographics of our country are rapidly changing. This makes attracting, treating and retaining patients of diverse backgrounds more important than ever before. Doctors in diverse communities that implement culturally competent practice management strategies will grow their businesses, expand their clinical skills and provide better patient care.

As emerging and underserved ethnic groups such as African-Americans and Asian-Americans continue to grow, we can solidify our position as Americas primary eye doctors by ensuring that our practices provide culturally competent care. (See Open Your Doors to Hispanic Patients.) This article looks at the market demand and opportunities presented specifically by African-American and Asian-American patients and how to supply culturally competent care through improving cross-cultural communication.

What is Culturally Competent Care?

Culturally competent care is providing care that understands and respects differences in cultural behaviors and perspectives and values cross-cultural communication. We all provide some level of culturally competent care in our practices. If you use the tumbling E acuity chart or have toys in your waiting area, your practice is providing culturally competent care to pediatric patients. The federal government mandates that we provide handicap accessibility to patients with physical disabilities. This is providing considerate and competent care to patients who are physically challenged. In both examples, the doctor understands the groups differences and addresses these differences to improve the care provided.

Creating a culturally comfortable environment may involve physical changes in your office like displaying reading materials or diverse point-of-purchase materials. It also involves communication changes on behalf of the doctor and staff to ensure that we attain the vital information needed during the encounter and that the patient understands the treatment plan.

Communicating cross-culturally does not require that we speak the same language. It does, however, require us to understand the cultural beliefs that we and our patients bring to the doctor-patient relationship and how they might impact care. For example, an Asian-American patient may not look directly at me during the examination. I must understand that in some Asian cultures, this is a sign of deference and respect for the doctors position of authoritynot a sign of an inattentive patient.


The Demand

The population of Asian-Americans is growing at a rapid pace. The Asian population in the U.S. is projected to climb from 15.5 million in 2008, or 5.1% of the nations population, to 40.6 million by 2050, or 9.2% of the population, according to the U.S. Census.1 In addition, Asian-Americans have a high rate of myopia and the highest median-family incomes in America. According to the U.S. Census Bureau 2008 Annual Social and Economic Supplement, the median household income of Asian-Americans was $65,876 per year compared to $50,233 for all Americans. When we combine the rate of population growth, incidence of myopia and the disposable income of the Asian-American population, it presents a compelling economic reason to ensure that our practices provide an environment that is sensitive to the specific needs of the culture.

African-Americans represent 13.8% of the U.S. population.1  According the U.S. Census Bureau, the African-American population is projected to increase from 41.1 million in 2008 to 65.7 million, or 15% of the population, in 2050. African-Americans have the highest rate of glaucoma in America, further increasing their demand for eye care. Glaucoma is the leading cause of blindness among African-Americans and is six to eight times more common in African-Americans than in whites. In addition to this higher frequency, glaucoma often occurs earlier in life in African-Americanson average, about 10 years earlier than in other ethnic populations.2 
In addition, African-Americans are 1.6 times more likely to have diabetes than non-Hispanic whites. African-Americans are almost 50% as likely to develop diabetic retinopathy as non-Hispanic whites.3

Most of our practices have a retail optical component and African-Americans are strong consumers. Style and fashion tend to be a key part of the African-American culture. This presents an economic opportunity for the practice and a challenge to keep the optical current with product that is appealing to the fashion focused African-American consumer.

African-Americans, Asian-Americans and Hispanic Americans together represent tremendous purchasing power. According a recent analysis, the combined purchasing power of African-Americans, Hispanic-Americans and Asian-Americans was estimated at $2.37 trillion in 2008.4 Practices that focus on providing the products that these patients want in an environment that is welcoming with staff that is trained in effective cross-cultural communication will realize a significant economic gain.


The Supply

Despite the many advances in health care for minorities, disparities still exist in morbidity and mortality rates as well as utilization of health services. Certainly, disparities exist due to access and economics. However, some disparities exist due to differences in cultural perspectives on health care. For example, in certain Asian cultures, patients may perceive less than perfect vision as a flaw and believe that their vision would be improved if they had taken better care of eyes. Educating patients on the role that genetics plays in refractive error can be an important part of the care provided.

Optometry plays an important role in our nations public health efforts to reduce health care disparities because we are often the entry point into the health system for minority patients. For patients who may not seek regular medical care, our offices become their entry into the health care system as they seek drivers licenses and vision improvement for work.


Resources for Culturally Competent Eye Care

U.S. Department of Health and Human Services, Office of Minority Health. (

National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care: Final Report. Bethesda, MD: U.S. Department of Health and Human Services, Office of Minority Health; March 2001. Available at:

Welch M. Culturally Competent Care for Diverse Populations. Bethesda, MD: U.S. Health Resources and Services Administration, Bureau of Primary Health Care; 1997.

Beamon C, Devisetty V, Forcina JM, et al. A Guide to Incorporating Cultural Competency into Medical Education and Training. Los Angeles, CA: National Health Law Program; 2005.

Kaiser Permanente National Diversity Council. A Providers Handbook on Culturally Competent Care: African American Population. 2nd ed. Oakland, CA: Kaiser Permanente; 2003. Available at:
Kaiser Permanente National Diversity Council. A Providers Handbook on Culturally Competent Care: Asian and Pacific Islander Population. 2nd ed. Oakland, CA: Kaiser Permanente; 2003. Available at:

Keys to Communicating

Lets examine a few of cultural values and perceptions commonly observed in Asian-American and African-American patients and keys to communicating effectively.

Asian-Americans. One of the perceptions that we have to manage for some Asian patients is that the optometrist is a refractionist, not a medical provider. Many first-generation Asian patients come from countries where refractions and the sale of optical products are not delivered along with eye health examinations. Some of these patients may be unwilling to pay for and may not understand that we provide complete health assessments along with refractions. It is important that we educate these patients on the services provided during a comprehensive eye examination.

Some Asian patients may appear stoic and not very expressive. This is due to the importance of maintaining emotional self-control and balance. It is important to know that pain may not be explicitly displayed. It is also important to understand that smiling expresses a variety of emotions. It can represent happiness or pleasure, or it may mask anger, frustration, embarrassment, disappointment or lack of knowledge. Often, the patient may respond yes to be polite and avoid conflict, even when he or she does not understand.

Our speech tempo is typically quicker than in most Asian cultures and it can give the impression of rushing them through the encounter. Some Asian-American patients may also be intimidated by the directness of our questions. In some Asian cultures, shaking hands may not be polite and a bow is appropriate. A limp handshake shows humility and respect.

Effective cross-cultural communication with Asian-Americans doesnt require that we speak their language. The most important thing we can do is to slow down and take longer periods of silence. It is important that we spend the time to address their needs and not appear rushed. We should also be less direct in questioning and show respect by addressing patients by their appropriate title and family name.

It is also important that we educate this group of patients on the purpose, value and scope of eye examinations. It is equally important that we understand that some Asian-American patients believe in such Eastern medical doctrines as herbology, acupuncture, chiropractic, massage, spiritual healing, meditation and diet. Do not discount those beliefs not held by Western medicine. Often, patients are afraid to tell caregivers that they are receiving alternative medicine concurrently with Western treatment, because in the past they have experienced ridicule. Inquire about alternative therapies the patient may be receiving, ensure that there are no contraindications with the treatment we prescribe, and show respect for the patients belief if it does not impair successful outcomes.

African-Americans. In contrast to Asian-Americans, African-Americans tend to understand that the optometrist is a health care provider, and they expect the optometrist to address their visual and ocular health needs. In most cases, the optometrist is seen as a health care provider, and discussions of the eyes relationship to serious health diseases, such as hypertension and diabetes, are generally well received.

Although the African-American patient may be aware of our role in their health care, one of the challenges all health care providers face is that three of the most common and devastating medical conditions that we see in African-Americans are often asymptomatic until far along in the disease process. Hypertension, diabetes and glaucoma are rampant in the African-American community and many in the community are undiagnosed. (The National Optometric Association has spearheaded a nationwide public health initiative called the Three Silent Killers to raise the awareness of these conditions in the African-American community. Contact the NOA for details and office brochures to help address these devastating conditions at
1-877-394-2020 or

One of the barriers to building a culturally competent practice in the African-American community is often overcoming a level of mistrust. Past injustices may cause some patients to distrust their providers. Establishing trust with the African-American patient is the key to providing the best care. Once trust and respect are established with an optometrist and his or her staff, African-American patients are extremely loyal to the practice.

Our communication style can help establish trust with African-Americans. Most of us are taught to separate our professional and personal identity when caring for patientsthe need to maintain objectivity in patient care can depersonalize our communication style. But, the African-American culture tends to value personalized and friendly doctor-patient relationships. It is expected that we will treat them professionally, but personal connections, in which we show interest in their family, jobs and personal relationships, help establish a level of trust in the doctor-patient relationship.

A welcoming environment projected by our office and staff members is important as well. Choose magazines, artwork and health care brochures that reflect positive images of African-Americans and clinical information and solutions for African-Americans. When greeting African-American patients for the first time, address them as Mr. or Mrs. or by their professional title and last nameits a demonstration of understanding and respect.

Community outreach is a valuable way to establish trust in the African-American community. Ministers, civic leaders, educators and coaches are influential. If we educate them about the importance of eye care, they will spread our message to their constituents.

As in most families, African-American mothers make the medical decisions. Recommendations from mothers and elders are very influential. We also find that African-American mothers can sometimes be suspicious of traditional medicine and often seek non-traditional medical advice from friends and other sources. Inquiring about alternative treatments and respecting their beliefs is important in this culture as it is in Asian-American cultures.

Cultural competence is a journey. There are many resources available to help practitioners and staff members develop the tools needed. I have listed a few of the resources that I have found most valuable (see Resources for Culturally Competent Eye Care"). If we are open to learning other cultures, understanding our own biases and modifying our office environments and communication patterns to facilitate effective care, we will improve patient outcomes and build strong practices. Good luck on your cultural competency journey.

Dr. Artis is currently vice president of vendor relations for Vision Source, in Kingwood, Tex. He lectures extensively on practice management, culturally competent health care, contact lenses and eye care.


1. U.S. Census Bureau. 2008 National Population Projections Tables and Charts. Available at:  (accessed May 8, 2009).

2. Glaucoma Research Foundation Web site. African-Americans and Glaucoma. Available at: (accessed May 8, 2009).

3. American Diabetes Association Web site. African American and Diabetes Facts. Available at: (accessed May 8, 2009).

4. Humphreys JM. The Multicultural Economy. Athens, GA: The Selig Center for Economic Growth, Terry College of Business, The University of Georgia; July 2008:7-18. Available at: (accessed May 8, 2009).

Vol. No: 146:06Issue: 6/15/2009