Article Date: 6/1/2009

BUILD A <i>Culturally Aware</i> Practice

BUILD A Culturally Aware Practice

Attracting and retaining diverse patients is vital to your practice's health. Here are three steps to accomplish this.

Baltimore, MD


Merriam Webster defines diversity as "the condition of being diverse: variety; the inclusion of diverse people (as people of different races or cultures) in a group or organization."1

The latest U.S. Census Bureau data (2007 to 2008) reveals that our country is becoming more racially and ethnically diverse. As of July 1, 2008, the overall minority population (any group other than single-race, non-Hispanic white) was 104.6 million, or 34% of the total U.S. population.2 The largest and fastest-growing minority group: Hispanics (which includes Latino), reaching 46.9 million in 2008. In fact, almost one in six U.S. residents were Hispanic in 2008.

To stay competitive and maintain a successful practice, you must attract and retain diverse patients. You can easily accomplish this by making yourself and your practice more culturally aware.

The three ways to do this:

1. Identify your practice population

Determine the specific demographics of your practice's location. The most recent U.S. Census Bureau data breaks this down by county and state.

Six U.S. counties became majority-minority (more than half the population being of a group other than single-race, non-Hispanic white) between 2007 and 20083 Orange County, Fla. took the lead with slightly more than 50% minority populations, including 25% Hispanic and 22% Black populations. Stanislaus, Calif.; Finney, Kan.; Warren, Miss.; Edwards, Texas; and Schleicher, Texas also became majority-minority counties in 2008. Further, almost 10% (309) of the 3,142 U.S. counties were majority-minority as of July 1, 2008. Of that total, 56 have become majority-minority since April 1, 2000. Of interest: Webster County, Ga. was majority-minority in 2007, though lost this designation in 2008.

Starr County, Texas had the highest minority population (98%) in 2008, followed by the state's Maverick County (97%) and Web County (95%). Hispanics represented the vast majority of the minority populations in all three counties.

The majority-minority states for 2008: Hawaii (75%), New Mexico (58%), California (58%) and Texas (53%). The District of Columbia is 67% minority. No other state exceeded a 43% minority population.

The U.S. Census Bureau data of specific diverse populations to note:

American Indians and Alaska Natives (AIAN). Calif. had the greatest AIAN population in July 2008 (739,000). Texas had the largest numeric increase in the AIAN population since July 2007 (13,000), and Alaska had the highest percentage of AIAN (18%) residents. County-wise, Los Angeles County, Calif., had the greatest AIAN population in July 2008 (155,000); Maricopa County, Ariz. (Phoenix) had the greatest numeric increase of the AIAN population (2,300) since July 2007; and Shannon County, S.D. had the greatest percentage of AIAN (88%) residents. In fact, Shannon County was one of 10 majority-AIAN U.S. counties.

Asians. Calif. had both the largest Asian population of any state (5.1 million) in July 2008 and the biggest numeric increase of Asians since July 2007 (105,000). Hawaii was the only majority-Asian state (54% of the total population). County-wise, Los Angeles County, Calif., had the greatest Asian population (1.4 million) in July 2008; Santa Clara County, Calif. (San Jose) had the biggest numeric increase (19,000) since July 2007; and Honolulu County, Hawaii — at 58% — was the only majority-Asian county in the nation.

Blacks. N.Y. State had the greatest Black population as of July 1, 2008 (3.5 million), and Ga. had the biggest numeric increase since July 1, 2007 (67,000). The District of Columbia had the greatest percentage of Blacks (56%), and Miss. (38%) ranked second. County-wise, Cook County, Ill. (Chicago) had the greatest Black population (1.4 million); Orleans Parish, La. (New Orleans) had the biggest numeric increase of Black residents since July 1, 2007 (16,000); and Claiborne County, Miss. had the greatest percentage of Black residents in the nation (84%). Of interest: A total of 77 counties — all in the South — were majority Black.

Hispanics. Calif. had the greatest Hispanic population of any state as of July 2008 (13.5 million). And, it had the biggest numeric increase within the Hispanic population since July 2007 (313,000). N.M. had the greatest percentage of Hispanics (45%). County-wise, Los Angeles County, Calif., had the greatest Hispanic population (4.7 million) in 2008 as well as the biggest numeric increase since 2007 (67,000). Starr County, Texas had the greatest share of Hispanics (97%). And, of the 48 majority-Hispanic counties nationally, Texas had the top 10.

Native Hawaiians and Other Pacific Islanders (NHPI). Calif. had the greatest population of NHPI (282,000) in July 2008, and the biggest numeric increase in this population since July 2007 (6,000). Hawaii had the greatest percentage of NHPI (22%). County-wise, Honolulu County, Hawaii had the greatest NHPI population (179,000) in July 2008; Clark County, Nev. (Las Vegas) had the biggest numeric increase of this population since July 2007 (857). And, Hawaii County, Hawaii had the greatest NHPI percentage (30%).

Non-Hispanic White Alone (NHWA). Calif. had the greatest population of NHWA as of July 2008 (15.5 million); Texas had the biggest numeric increase of this population since July 2007 (85,000); and Maine and Vermont had the greatest percentage of NHWA individuals (95% each). County-wise, Los Angeles County, Calif. had the greatest population of NHWA (2.8 million) in July 2008; Maricopa County, Ariz. had the biggest numeric increase of this population since July 2007 (22,000); and Magoffin County, Ky had the greatest percentage of NHWA residents (99 percent).

Remember: These are just highlights of recent U.S. Census Bureau data. For specific information on your county and state, visit The U.S. Census Bureau Web site at Also, keep your eye out for the United States Census 2010 data, which will paint an even more accurate picture of your state and county demographics (available April 1, 2010).

2. Determine your practice population's health risks

Once you've identified the diverse populations that reside within your practice's location, ascertain the specific health and ocular issues related to these patients. Do this by conducting a quick search of PubMed (, visiting the Kaiser Family Foundation Web site (, which provides general information on minority health, and your local library to determine local/regional cultural organizations, places of worship, etc.

Examples of the health and ocular issues that commonly present in specific patient populations:

► Visual impairment, cataract, glaucoma and diabetic eye disease are all prevalent in the Alaska Natives.4

► Overall, Asian Americans and NHPI are less likely than non-Hispanic whites to have a chronic condition; however, they are less likely to have employer-sponsored health coverage and more likely to be uninsured.5

► Research continues to show that Hispanics and Blacks have a higher prevalence of diabetes than Whites.6 In fact, Blacks have a four to five times higher prevalence of this condition than Whites.7

► Glaucoma cases among older Hispanics (age 65 and older) who have diabetes is projected to increase 12-fold by 2050.8

► Hispanics also have a high prevalence of age-related diseases (e.g. type II diabetes), open-angle glaucoma, cataracts and one of the highest rates of undetected eye disease and visual impairment associated with eye disease in the United States.8

► A total of 78% of strabismus and amblyopia cases in Hispanic and Black children were attributable to refractive error, says one study.9

The purpose of these examples is to demonstrate the importance of (1) why you need to research the demographics of your practice location and (2) how doing so can enable you to pinpoint the services these populations need and what to expect.

Education is particularly crucial to garnering diverse patients and preventing eye disease. Vistakon's recent "Americans' Attitudes and Perceptions About Vision Care Study" revealed cultural differences exist regarding attitudes toward vision care.10 The results came from both an online and telephone survey of 3,716 respondents ages 18 and older. Respondents identified themselves as Hispanic (690), Black (676), Asian-American (686) or White (1,566). Study highlights:

► Overall, White respondents (81%) were significantly more likely to have been diagnosed and/or treated with a vision condition than Asian-Americans (71%), Hispanics (66%) and Blacks (66%).

► Black respondents were the most likely (72%) to "strongly agree" that maintaining vision is an important priority. Asian-Americans were least likely (55%) to "strongly agree" with this statement.

► Black patients were most likely to "strongly agree" (50%) that taking care of their eyes is as important as other health issues. Asian-Americans (28%) were least likely to "strongly agree" with this statement. Still, Black respondents were also the most likely to report they don't have a regular eyecare professional (21%).

► More than one in four (27%) Hispanic respondents said they "strongly agreed" that worsening eyesight was a major concern, compared with just 15% of all respondents. But, Hispanic respondents vs. the other groups were the least likely to have presented to an eyecare practitioner in the last year (43%).

► More than nine out of 10 Asian-American respondents agreed that maintaining proper vision is an important priority, though more than a third said they didn't need an eye exam unless they were experiencing a vision problem. Also, Asian-American respondents vs. the other groups were least likely to believe vision correction greatly improves driving, work performance, computer work and reading performance.

► White respondents vs. the other groups were significantly more likely to say they knew exactly what myopia/nearsightedness, hyperopia/farsightedness, astigmatism and presbyopia are.

► White patients vs. the other groups were significantly more likely to know that available treatments exist for glaucoma, cataracts, myopia and hyperopia, astigmatism, presbyopia and age-related macular degeneration.

► Although a majority of white respondents (71%) said they believed that people should present for an eye exam at least annually, 25% said they haven't seen an eye doctor in the past two years.

Given these compelling findings, you must reach out to the demographics of your practice, and educate them about the importance of eye care. Consider sponsoring cultural festivals and religious events and supporting public health efforts targeted toward specific patient groups (e.g. community center health fairs and educational programs). Make yourself known to these organizers, and develop a good relationship with a specific contact with which to network. Also, contemplate organizing a free vision seminar tailored to your demographics at a local community center, and advertise the event throughout the community (e.g. bilingual publications, school and community newsletters). Attendees will likely become your patients and refer family members and friends to your practice. In-office surveys and staff inquiry can track response rates from the event (and get suggestions for future events) and reinforce the value of your team's efforts. One caveat: Organize such an event only with a well-developed cultural competency background (see below).

3. Develop cultural competency

Now that you have identified the demographics of your practice's location and the health and ocular issues common to these groups, you must become culturally sensitive. This requires you to conduct research on and develop cultural competency.

Cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations, according to The Office of Minority Health (OMH) (a branch of the U.S. Department of Health and Human Services).11

The OMH defines culture as integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups. By obtaining cultural competency, you ensure a patient feels comfortable with you, your staff and the marketing and educational materials you provide. OMH ( and the National Center for Cultural Competence ( offer education and tools for healthcare practitioners to develop cultural competency. Further, the American Optometric Association (AOA) and companies including Vistakon and Transitions Optical, Inc. provide cultural competence education specifically geared toward you.

In 2008, the AOA formed the Hispanic Communications Project Team. It's goal: to help O.D.s better serve the growing U.S. Hispanic population by working on developing doctor-patient tools and resources on Hispanic eye health care needs/risk factors and positioning O.D.s as primary eye healthcare professionals among the Spanish-speaking U.S. population. Thus far, it has developed and mailed to its members located in areas that have significant Hispanic populations a patient needs assessment guide. This year, the team has been working on creating resources to build an understanding among O.D.s of the Hispanic market, its unique risk factors and how to expand media and public awareness outreach targeting this population.

Vistakon held a presentation at SECO International in 2007 called "Cultural Diversity in Eye Care." It included a group of actors who demonstrated through different scenes the various cultural faux pas that eyecare practitioners and their staff often make when caring for Black, Hispanic, Asian and Muslim patients.

In one scene in which a Black man presents for an eye exam, he discovers none of the waiting room periodicals are specific to his culture. The actor pointed out that by not having appropriate literature for his culture (e.g. Ebony magazine), he felt as if he wasn't welcome in the practice This is a good example of a non-verbal culturally insensitive message.

The acting group also asked audience members to weigh in on the cultural mistakes noticed during the scenes and potential resulting consequences of these mistakes on a practice, such as losing the patient or even incurring a lawsuit.

In addition, O.D.s who represented the individual cultures portrayed in the scenes discussed demographics, specific cultural differences and the buying power of their respective cultures with the audience. (You can obtain a DVD of the entire presentation by e-mailing Vistakon at theinsti

Transitions Optical Inc. offers Spanish-language or bilingual education and tools, such as a bilingual pocket card, to eyecare practitioners.

Most recently, the company hosted a roundtable in Washington, D.C. titled "Cultural and Linguistic Considerations For Vision Care," in which they invited diversity experts in eye care and health care. The purpose of the roundtable: to "better understand how to overcome challenges to providing vision care to multicultural populations." The roundtable included an in-depth discussion of the Culturally and Linguistic Appropriate Services (CLAS) standards developed by the OMH to improve healthcare access and quality for minorities.12

CLAS standards experts and eyecare professionals analyzed the CLAS standards and determined that one element in particular could enable eyecare practitioners to provide adequate services to diverse populations: easily understood, in-language patient materials and signage.

In addition, participants agreed that having interpreters accompany diverse patients would be helpful. Further, all participants stressed the need for an increase in the representation of diverse populations within the eyecare industry itself and how early cultural awareness education in schools and colleges of optometry and opticianry schools could make a difference in improving cultural competence in eyecare practices.

A roundtable consensus paper containing presenter insights and tips for adopting aspects of the CLAS standards for use in your practice will be available on and through customer service later this month. Also, Transitions Optical is currently working on corresponding continuing education and an Eye Care Communication Guide.

Diversity is a part of the fabric of our country, and it continues to weave its way into important considerations for optimum public health. As a result, to remain competitive and maintain a successful practice, making your practice culturally aware is a must. OM

1. Merriam-Webster OnLine Dictionary. (Accessed May 1, 2009.)

2. U.S. Census Bureau. Newsroom. U.S. Census Bureau News. Released: Thursday, May 14, 2009. Census Bureau Estimates Nearly Half of Children Under Age 5 are Minorities: Estimates find nation's population growing older, more diverse. (Accessed May 15, 2009).

3. U.S. Census Bureau. Newsroom. U.S. Census Bureau News. Released: Thursday, May 14, 2009. Census Bureau Releases State and County Data Depicting Nation's Population Ahead of 2010 Census: Orange, Fla. joins the growing list of ‘majority-minority’ counties. (Accessed May 15, 2009).

4. Haymes SA, Leston JD, Ferucci ED, et al. Visual impairment and eye care among Alaska Native people. Opthalmic Epidemiol. 2009 May-Jun; 16(3): 163-74.

5. Kaiser Family Foundation. Health Coverage and Access to Care Among Asian Americans, Native Hawaiians and Pacific Islanders. Race, Ethnicity & Health Care Fact Sheet. April 2008. Available at Accessed May 1, 2009.

6. Saadine JB, Honeycutt AA, Narayam KM, et al. Projection of diabetic ret-inopathy and other major eye diseases among people with diabetes mellitus: United States 2005-2050. Arch Ophthalmol. 2008 Dec; 126(12): 1740-1747.

7. Tielsch JM, Sommer A, Katz J, et al. Racial variations in the prevalence of primary open-angle glaucoma. The Baltimore Eye Survey. JAMA 1991 Jul 17;266(3):369-74.

8. Varma R, Mohanty S. Deneen J, et al. Burden and predictors of undetected eye disease in Mexican-Americans: the Los Angeles Latino Eye Study. Med Care 2008 May;46(5):497-506.

9. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months the multiethnic pediatric eye disease study. Ophthalmology 2008 Jul;115(7):1229-36.

10. The Vision Care Institute of Johnson & Johnson Vision Care, Inc. Americans' Attitudes and Perceptions About Vision Care. March 8, 2006 to March 27, 2006. (To obtain the report, e-mail the in

11. U.S. Department of Health and Human Services. The Office of Minority Health. What is Cultural Competency? ?lvl=2&lvlID=11 (Accessed May 15, 2009.)

12. U.S. Department of Health and Human Services. The Office of Minority Health. National Standards on Culturally and Linguistically Appropriate Services (CLAS). lvl=2&lvlID=15 (Accessed May 15, 2009.)

Dr. Grover is an assistant professor of ophthalmology at the Wilmer Eye Institute, Johns Hopkins University School of Medicine and has specialized in vision impairment and rehabilitation for more than 18 years. She's currently chair of the American Optometric Association Low Vision Rehabilitation Section. You can e-mail her at

Optometric Management, Issue: June 2009