What Should Students Learn About the Importance of Cultural Brokering in Immigrant Communities?

Jane  Lee; Gabriel  Robles; Latoya  Small

doi:10.1001/amajethics.2023.809.

Medical Education

Nov 2023

Peer-Reviewed

What Should Students Learn About the Importance of Cultural Brokering in Immigrant Communities?

Jane Lee, PhD, MSW, Gabriel Robles, PhD, LCSW, and Latoya Small, PhD, MSW

AMA J Ethics. 2023;25(11):E809-817. doi: 10.1001/amajethics.2023.809.

Abstract

Cultural brokers can help clinicians meet needs of immigrant patients. This article considers loneliness as an endemic experience of immigrants in the United States and discusses how cultural brokerage practices can reduce the ill health effects of loneliness by helping clinicians contextualize their interactions with immigrant patients and by helping immigrants navigate the health care system and build social connections.

Immigrant Health

More immigrants live in the United States (US) than any other country in the world,¹ and an estimated 1 million immigrants arrive in the US each year.² While the country’s growing immigrant population is highly diverse in its origins and experiences, after arriving in the US, many immigrants face challenges navigating health care and social systems. Immigrants may be particularly susceptible to unfavorable conditions for achieving good health, as factors such as legal status, socioeconomic status, language barriers, and discrimination can limit opportunities to access high-quality health services.^3,4,5For example,over half of all immigrants are noncitizens,⁶ who are uninsured at higher rates than their US-born or naturalized counterparts and therefore encounter greater health care costs and fewer options when seeking specialized care.⁷ Furthermore, approximately 13% of foreign-born families live in poverty compared to 11% of US-born families,^6,8 which can render health care a major financial burden.

Obstacles to accessing adequate health services are among the many stressors associated with living in a new or unfamiliar environment. Immigrants confront systemic barriers, including racism and cultural and social marginalization, which can prevent them from integrating into society.⁹ Loss of familiar social relationships or networks as a result of migration can evoke feelings of loneliness,¹⁰while policies and norms that ostracize immigrants, such as eligibility restrictions on public benefits like health insurance,¹¹ can engender isolation.¹² A growing number of studies have documented increased loneliness among immigrant groups in the US.^13,14,15,16 Moreover, research has demonstrated associations between loneliness and greater risks of physical and mental health conditions,¹² including high blood pressure, depression, anxiety, and cognitive decline.^17,18,19,20

Extant research on approaches to reduce what has been called “structural loneliness,”²¹ while yielding mixed results, points to the importance of education, social cognition, and opportunities for social connection.^22,23 However, when designing interventions for loneliness, few researchers consider the impact of societal structures or contexts that influence interpersonal relationships and opportunities to connect among immigrant communities.²⁴ In other words, loneliness interventions seldom focus on the challenges that immigrants face in fostering relationships or on the differences and connections among culturally diverse groups.

This article explores cultural brokerage as a strategy for addressing loneliness in patients born outside the US. In health care, cultural brokers bridge cultural and social perspectives to facilitate health care utilization. We first draw upon multiple frameworks—including cultural competency, cultural humility,²⁵ and structural competency²⁶—to recommend health service delivery strategies in diverse communities, especially immigrant communities. We then focus on understanding how cultural brokerage can influence immigrants’ health experiences and mitigate loneliness. Finally, by identifying the roles and skills of cultural brokers, we demonstrate how cultural brokerage can be integrated into clinical practice.

Key Concepts

The US health care system reflects the nation’s culture, priorities, and approaches to supporting people’s well-being. Despite its intention to enhance quality of life through improved health, this system can produce negative health outcomes for socially vulnerable communities.²⁷ Immigrants who face obstacles accessing health care can experience discrimination from clinicians, medical mistrust, and low treatment adherence,^28,29,30,31 impairing the patient-clinician relationship. Several factors influence relationships between clinicians and patients. In particular, sociodemographic factors, such as patient race/ethnicity, income, and education, have been shown to be correlated with patients’ perceptions of and relationships with clinicians.³² In particular, lack of trust can affect patient satisfaction and other health outcomes.³³

Attention to these factors has led to the development of structural competency trainings on how structural factors, such as social and economic policies and social stratification, can influence health.^26,34Cultural competency training responds to the disparities in health outcomes experienced by minoritized groups by seeking to increase clinicians’ understanding of patients’ sociocultural backgrounds and cultural values³⁵ and to develop knowledge, behaviors, and skills that promote effective service delivery for diverse communities and populations. Yet, given the diversity of immigrants’ experiences across and within communities, calls for cultural humility training have emerged to avoid potential stereotyping or othering of patients through decontextualized “competence” training.³⁶ Specifically, cultural humility involves clinicians reflecting on their own beliefs, values, and biases and adopting a person-centered approach to allow patients to share their perspectives and experiences. Through patient-centered care, clinicians “meet patients where they are,” which allows trusting relationships to be built.^35,36 Thus, while cultural competency tends to focus on clinician knowledge and skills, cultural humility aims to enhance the clinician’s capacity to integrate patients’ points of view and to communicate with diverse patients. Cultural competency and cultural humility both shape the delivery of culturally sensitive care, which emphasizes awareness of cultural differences to enable patients to feel comfortable and respected during the health care visit.

Rather than perceive culturally competent health care through a binary lens in which care is or is not culturally competent, it might be more appropriately understood as a continuum along which care can be more or less culturally sensitive.³⁷ Shared characteristics, experiences, and language between clinicians and patients can affect the nature of the relationship, potentially improving the quality of care.³⁸ Yet these characteristics alone are inadequate to the provision of culturally sensitive care.³⁹ For example, while providing services in patients’ preferred language is important for culturally sensitive care, it is inadequate for ensuring that patients feel understood and empowered. By prioritizing patients’ perspectives, needs, and preferences, clinicians can work toward delivering care that is more culturally sensitive. Notably, patient-centered communication can empower patients and enable the clinician to understand the personal and context-specific experiences of the patient.⁴⁰

This creation of meaningful linkages between worldviews or systems has been described as “cultural brokerage.”⁴⁰ While the concept of cultural brokerage was established in the social and anthropological literature,⁴⁰ the skills, identities, procedures, and orientations of individuals who have engaged in cultural brokering predate any formal or prescribed recognition of their roles. In health care settings, cultural brokerage involves bridging or mediating between the patient and the health care system,⁴¹ which can be highly relevant for immigrants as they seek integration into new communities. Patients may derive greater understanding of health systems and services from their own cultural perspectives as the result of cultural brokerage. Hence, cultural brokerage does not exclude culturally sensitive care; rather, it can enhance delivery of culturally sensitive services, allowing care to be more robust and relevant for immigrant groups. Despite acknowledgement of the vast potential of cultural brokerage in improving the health of immigrants in the US,⁴² greater information on who should engage in cultural brokerage and how to apply specific skills and in which contexts is needed to harness this potential.

Cultural brokerage can be a form of labor that is not adequately compensated or valued.

Any individual has the potential to act as a cultural broker. Whether a particular individual does or can do so well is contingent upon context—specifically, on the knowledge, skills, and networks involved.⁴³Cultural brokers act in varied settings and capacities and can have extensive or little or no training.⁴³ Children of immigrant families, for example, are often de facto cultural brokers who help their parents interact with mainstream US culture.^44,45,46 In health care settings, social workers and nurses can be described as cultural brokers when, in the course of close work with patients, they gain in-depth understanding of their patients’ perspectives^47,48,49and are able to broker key interactions between health systems and patients.⁴⁰

Patient-Centeredness

Immigrants’ challenges to receiving high-quality health services are often the same ones that health care providers and clinicians encounter in providing culturally sensitive care.⁴⁸ Lo explains that clinicians rarely know a patient’s culture a priori, given that patient culture includes broad orientations and cultural schemata that are multiple, intersecting, and adaptable.⁴⁰ Thus, patient-centered, empathic communication with culturally diverse patients is vital not only for patient satisfaction but also for helping clinicians understand the impact of structural forces such as migration, poverty, religion, and language on patients.^34,50

This patient-centered attribute of cultural brokers demonstrates that the role of cultural broker is not a static one that is attained and kept but rather a set of skills and motivations that require constant growth.⁴³Clinicians can act as cultural brokers by sharing authority with patients in clinical interactions, which involves paying attention to differing patient expectations of and experiences with health treatment and prevention models.⁴⁰ Certain interventions or approaches to care may not apply to all patients. Hence, cultural brokers—across different modes of medical and clinical practice—must establish shared understanding of the roles of different health professions to build therapeutic alliances across social divides.

Emphasis on relationship building is also key to cultural brokerage. By approaching interactions with immigrant patients as part of a long-term relationship, clinicians can integrate into their work the multiple and intersecting schemata that shape the patient’s culture.⁴⁰ Relationship building also allows for the development of trust and mutual respect. As trust forms, consistency, communication, and continuity of care can be strengthened, which are important for immigrants whose complex cultural environmental influences can take time to understand.

Brokering and Loneliness

The increased understanding, trust, and empowerment that result when clinicians act as cultural brokers can have positive effects beyond the interpersonal relationship. Specifically, brokerage can shape policy and program development as immigrant voices become centered and validated.⁵¹ When immigrants feel heard and understood, they are less likely to feel isolated or excluded from the social environment.¹⁶ Furthermore, immigrants can obtain greater social support by building longer-lasting relationships with clinicians, which can reduce the likelihood of their experiencing loneliness and other poor health outcomes.⁵² By gaining skills and acting as cultural brokers, clinicians in the health care system can bolster the health and well-being of immigrant communities, potentially impacting the cultural approaches of clinics and hospitals where services are delivered.

While the benefits of clinicians as cultural brokers are clear, there may be a lack of resources to support them in this role. Cultural brokerage can be a form of labor that is not adequately compensated or valued. In already under-resourced health care settings, cultural brokerage can increase the strain on overburdened clinicians with stressful workloads.

Utilization of community health workers can fill the gaps in the provision of culturally sensitive health education for minoritized communities.⁵³ Community health workers, who have been identified by several different titles such as lay health advocates and peer health educators, often share the ethnic background, language, and life experiences of the communities they serve.⁵⁴ Hence, they often draw upon these experiences to serve as cultural brokers by bridging the service provision gap between community members and the health system. While clinicians are not required to have the same cultural background as their patients to be cultural brokers, developing a depth of knowledge regarding the history, cultural background, and lived experiences of the populations they work with is vital to their roles as brokers. Furthermore, partnering with existing cultural brokers across specialties, such as community health workers, can strengthen the provision of culturally sensitive services.

Community health workers do not substitute for clinicians or other allied health care workers, but their roles as cultural brokers highlight the importance of patient-centered approaches to care and the importance of meaningfully connecting with all patients. Fostering social connection between clinicians and patients is likely best considered as part of a multipronged health system strategy to reduce loneliness among immigrants in their new communities.

Brokering as Practice

Cultural brokers often wear several hats and have numerous responsibilities. Immigrant patients may require multiple cultural brokers to help them access different services based on their various needs and backgrounds. Bierschenk suggests that, rather than conceptualizing brokers as social types, “we should speak of brokerage as a bundle of social practices or a social role.”⁵⁵ Hence, rather than viewing the role of cultural broker as competing with that of medical provider or clinician, cultural brokerage can and should complement the provision of effective health care delivery. In practice, cultural brokerage aligns with the AMA Code of Medical Ethics’ emphasis on the physician’s dedication to providing competent medical care, respecting the rights of patients, and supporting access to medical care for all people.⁵⁶ Therefore, the mechanisms of cultural brokerage should be embedded in the training and skill sets of health professionals and prioritized in cultivating relationships that can improve the health and well-being of immigrant populations in the US.

AMA Journal of Ethics^®

Illuminating the Art of Medicine

What Should Students Learn About the Importance of Cultural Brokering in Immigrant Communities?

Abstract

Immigrant Health

Key Concepts

Patient-Centeredness

Brokering and Loneliness

Brokering as Practice

Read More

References

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