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Culturally and Linguistically Appropriate Services in Wound Care

Culturally and Linguistically Appropriate Services in Wound Care

Culturally and Linguistically Appropriate Services in Wound Care

INTRODUCTION

Overview

Culturally and Linguistically Appropriate Services (CLAS) support safe, effective, and equitable wound care. The National CLAS Standards, developed by the U.S. Department of Health and Human Services (HHS) Office of Minority Health, outline how healthcare services should be delivered in a manner that respects patients’ cultural health beliefs, preferred languages, and communication needs.[1] For wound care clinicians, applying CLAS principles helps ensure that clinical decisions and care plans are understood, acceptable, and actionable for diverse patient populations. 

This topic provides an overview of CLAS principles applied to wound care.

Background

Definitions

    According to HHS [1]:

    • Culturally and linguistically appropriate services (CLAS): Services that are respectful of and responsive to individual cultural health beliefs and practices, preferred languages, health literacy levels, and communication needs and employed by all members of an organization (regardless of size) at every point of contact.
    • Social determinants of health: The conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.
    • Cultural and linguistic competency: The capacity for individuals and organizations to work and communicate effectively in cross-cultural situations through the adoption and implementation of strategies to ensure appropriate awareness, attitudes, and actions and through the use of policies, structures, practices, procedures, and dedicated resources that support this capacity.
      • Cultural competency: A developmental process in which individuals or institutions achieve increasing levels of awareness, knowledge, and skills along a cultural competence continuum. Cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communities.
      • Linguistic competency: The capacity of individuals or institutions to communicate effectively at every point of contact. Effective communication includes the ability to convey information - both written and oral - in a manner that is easily understood by diverse groups, including persons of limited English proficiency, those who have low literacy skills or who are not literate, those having low health literacy, those with disabilities, and those who are deaf or hard of hearing.
      • Cultural humility: A reflective process of understanding one’s biases and privileges, managing power imbalances, and maintaining a stance that is open to others in relation to aspects of their cultural identity that are most important to them. Cultural competency includes the commitment to practicing cultural humility.

    Relevance

    • Wound care depends on accurate assessment, clear communication, and patient adherence to treatment plans that often require ongoing self-care. Chronic wounds - such as diabetic foot ulcers, venous leg ulcers, arterial ulcers, and pressure injuries - often affect populations experiencing health disparities and limited English proficiency. 
    • Cultural beliefs about wounds, pain, body exposure, and traditional healing practices can influence how patients report symptoms and follow treatment recommendations. Language barriers may further affect wound assessment, informed consent, and education, increasing the risk of delayed healing and complications.
    • Using culturally responsive communication and appropriate language access in wound care improves patient understanding, engagement, and adherence. When wound care instructions are aligned with patients’ language preferences and cultural context, patients are more likely to perform dressing changes correctly, recognize signs of infection, and follow offloading, compression, and nutrition recommendations.
    • Incorporating CLAS principles into routine wound care practice supports patient safety, reduces disparities, and promotes optimal healing outcomes.
    OVERVIEW OF THE NATIONAL CLAS STANDARDS
    The National CLAS Standards, developed by the HHS Office of Minority Health, offer a framework for implementing Culturally and Linguistically Appropriate Services (CLAS).[2] CLAS is a broad concept that extends beyond cultural competency and humility in providers; it encompasses a wide range of organizational activities, from leadership and frontline staff to workforce development, community engagement, and patient data collection.

    Table 1 shows the National CLAS Standards, which provide 15 specific action steps that clinicians and organizations can use as a blueprint to advance health equity, eliminate health disparities, and improve the overall quality of care. 

    Table 1. The National Culturally and Linguistically Appropriate Services (CLAS) Standards
    Principal Standard:
    1. Provide effective, understandable, and respectful quality care and services that respond to cultural health beliefs and practices, languages, health literacy, and other communication needs.

    Governance, Leadership, and Workforce:
    2. Advance and sustain organizational governance and leadership that promotes CLAS through policy, practices, and allocated resources.
    3. Recruit, promote, equip, and support a governance, leadership, and workforce that respond to the digital, cultural and language needs of the population.
    4. Educate and train governance, leadership, and workforce regularly on CLAS practices and resources.

    Communication and Language Assistance:
    5. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
    6. Inform all individuals, in writing and orally, of the availability of language assistance services in English and other languages that serve their linguistic needs.
    7. Ensure the competence of individuals providing language assistance through training and certification, when available, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided and discouraged.
    8. Provide easy-to-understand digital and print materials and signage in the languages commonly used by the populations in the service area.

    Engagement, Continuous Improvement, and Accountability:
    9. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.
    10. Conduct ongoing assessments of the organization’s integration of CLAS-related activities and measures into quality improvement activities.
    11. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health outcomes and to inform service delivery.
    12. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic needs of populations in the service area.
    13. Partner with the community to design, implement, and evaluate cultural and linguistically appropriate practices and impact.
    14. Create culturally and linguistically appropriate processes to identify, prevent, and resolve conflicts, complaints, or grievances.
    15. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

    CULTURAL CONSIDERATIONS IN WOUND CARE

    In wound care, cultural considerations can be observed in scenarios such as the ones described in Table 2 below.

    Table 2. Cultural Considerations in Wound Care
    Cultural ConsiderationsExamplesPotential Approach
    Cultural beliefs about wounds and healingWounds may be viewed as a test of faith, imbalance, or punishment. Beliefs may influence acceptance of treatments (e.g., surgery, debridement).Ask open-ended questions: *“What do you believe is causing the wound?”*
    Traditional and alternative healing practicesUse of herbal remedies, poultices, oils, or spiritual healing (prayer, rituals). Some practices may delay healing or interact with prescribed treatments.Assess nonjudgmentally and evaluate for safety before discouraging use
    Modesty, gender preferences, and body exposurePreference for same-gender clinicians during wound assessment. Modesty concerns may limit exposure of certain body areas.Provide privacy, explain procedures clearly, and use chaperones or interpreters as needed
    Cultural dietary practices affecting wound healingReligious fasting or dietary restrictions may reduce protein, calories, or micronutrients. Some cultures emphasize plant-based diets with limited protein.Collaborate to identify culturally acceptable, protein-rich foods or supplements
    Pain perception and expressionPain expression varies: some cultures underreport pain; others express pain openly. Stoicism does not equal absence of pain.Use validated pain scales and reassess frequently

    Understanding Cultural Identity, Social Identity, Intersectionality

    It is often said, "We don't see things as they are; we see them as we are."[1]

    • Culture shapes our view of the world, or our worldview. It is how we make sense of things. This means two people may interpret the same situation differently, based on their cultural perspectives.
    • A patient does not approach a clinician without personal history, and similarly, clinicians do not arrive at work without their own. Each clinician brings their unique customs, beliefs, and values to every patient interaction.

    Cultural and Social Identities in Care Delivery

    • Each individual possesses a distinct cultural identity. This identity is a combination of many interconnected social identities such as race, religion, socioeconomic status, and sexual orientation. Each individual’s social identities represent each person’s belonging to various cultural groups. 
    • Cultural identity is dynamic and evolves over time and context. Because people embrace their various social identities in unique ways, the differences among individuals within a cultural group can be just as significant as the differences between people from different groups.

    Intersectionality in Wound Care

    • An individual's intersecting social identities create a unique set of life experiences that influence how the healthcare system perceives and treats them.
    • Intersectionality refers to the multiple social identities that merge at the individual level, reflecting interlocking societal systems of privilege and oppression (e.g., racism, sexism, heterosexism, and classism).[3]
    • This concept, often visually illustrated, is essential for acknowledging that patients from historically marginalized groups may experience unique forms of oppression that affect their wound care outcomes.

    Social Determinants of Health and Health Equity

    It is important to recognize the impact of social factors that contribute to worse health outcomes for members of certain social groups. Awareness of the social context that drives health disparities is an important part of delivering respectful, trustworthy, high-quality care.[1]
    • Social Determinants of Health Influence Health: a patient's health is influenced by factors outside of biology and health behaviors, including their social, economic, and political circumstances (e.g., housing, income, education, neighborhood, and access to care). These are known as Social Determinants of Health (SDOH). [4][5]
    • Health Disparities: people in non-dominant social groups (racial/ethnic minorities, lower socioeconomic status) generally experience worse health outcomes than dominant groups.
      • Examples: Higher rates of fair/poor health reported by racial/ethnic minority adults and those below the poverty threshold. [6]
    • Discrimination as an SDOH: discrimination (e.g., racism, sexism) is a key SDOH that contributes to health disparities. [7]
      • Chronic Stress: everyday and major discriminatory events cause chronic stress, leading to physiological wear and tear (allostatic load) that compromises health. [8]
      • Intersectionality: People in multiple marginalized groups (e.g., Black women) experience compounded discrimination and worse health outcomes (e.g., higher maternal mortality rates). [8]
    • Healthcare Quality as a SDOH: differences in the quality of care received are a driver of health disparities and are also considered a SDOH. People of color and American Indian/Alaska Native people often receive lower quality of care. [9]
      • Provider Bias: Disparities can result from provider biases, stereotyping, and mistreatment (e.g., inadequate pain management for Black patients due to mistaken beliefs). [10]
      • Patient Impact: Mistreatment or perceived discrimination in healthcare leads to patient shame, anxiety, and sometimes discontinuation of care, worsening overall health. [11]

    Cultural Competency, Cultural Humility, and CLAS

    Providing high-quality wound care for all patients requires understanding, respecting, and responding to their unique needs and preferences. This involves practicing both cultural competency and cultural humility.

    Relevance of Cultural competency, cultural humility in wound care: 
    • Improved Patient Outcomes: when patients feel respected and understood, they are more likely to trust the provider, openly discuss health concerns, and adhere to their wound care plan, which can lead to better healing.
      • Patient Perspective: "A patient has to trust the provider in order to answer questions freely about his or her health and problems he or she is having. If a patient does not trust the provider, the patient is going to hide things and hold things back." [12]
    • Addressing Health Inequities: Not everyone has the same opportunities to achieve their highest level of health or receives high-quality healthcare. Understanding the patient's context, including social determinants of health, is crucial for equitable care.

    Core Concepts:

    • Cultural Competency is a continuous, developmental process focused on developing the knowledge and critical thinking skills needed to work and communicate effectively in cross-cultural situations. It involves a commitment to:
      • Learning about one's own and others' cultural identities.
      • Awareness of others' beliefs, values, and communication preferences.
      • Adapting services to each patient’s unique needs.
      • Gaining new cultural experiences. [13]
    • Cultural Humility is a continuous, reflective process focused on self-examination, managing power imbalances, and maintaining a stance of openness and respect toward others' cultural identities. It involves a commitment to:
      • Self-reflection and examination of biases and stereotypes.
      • Acknowledging one's limitations.
      • Prioritizing the patient’s perspectives, beliefs, and values.
      • Recognizing and minimizing power differences inherent in the provider-patient relationship.
      • Continued growth and development over time. [14][15]

    How Competency and Humility Work Together:

    • They are complementary: Cultural competency provides the knowledge and skills (e.g., considering cultural values and communication norms), while cultural humility provides the stance (openness, collaboration, and self-reflection).[16]
    • Together, they equip clinicians with the awareness, openness, and knowledge to engage more effectively with their patients and improve the quality of care by understanding, respecting, and responding to a patient’s experiences, values, beliefs, and preferences.

    Actionable Steps for Wound Care Clinicians:

    • Acknowledge Past Failures and Bias: Clinicians should reflect on interactions where their judgments, biases, or professional power may have negatively affected patient care.
    • Prioritize Patient Concerns: During the visit, the clinician should ask, "What is most important to you in managing your wound/condition? What are your main concerns?"
    • Inquire about Barriers: The clinician should understand what may be getting in the way of appointments, lab tests, or adhering to the wound care regimen (e.g., transportation, childcare, work schedule).
      • Example: "The clinician would like to understand the patient's situation a little more so the clinician can help the patient get the care needed. What support or resources does the patient have for things like transportation and childcare?"
    • Recognize Social Determinants of Health (SDOH): A patient's life experiences, SDOH (like working two jobs and caring for grandchildren), and perceptions of healthcare significantly affect the patient's ability to manage health and wound care.
    • Collaborate on Solutions: The clinician should brainstorm ways the patient can stay healthy and meet his or her goals together (e.g., adjusting appointment times, finding community resources).

    LINGUISTIC ACCESS AND HEALTH LITERACY


    Effective and equitable wound care is fundamentally dependent on clear communication. For patients with Limited English Proficiency (LEP) or low health literacy, communication barriers can compromise the entire care process - from initial assessment to patient education and adherence to complex treatment plans. Linguistic access and health literacy are core components of Culturally and Linguistically Appropriate Services (CLAS) and are essential for ensuring that all patients fully understand their condition and actively participate in their healing journey. 

    The suggestions below support Linguistic Access and Health Literacy in wound care:
    • Importance of Clear Communication
      • Accurate wound assessment depends on patient-reported symptoms (pain, drainage, odor, duration).
      • Clear instructions improve adherence to wound care, offloading, and follow-up.
      • Miscommunication increases risk of infection, delayed healing, and readmissions. [17]
    • Use of Qualified Medical Interpreters
      • Use trained medical interpreters for patients with limited English proficiency (LEP).
      • Avoid ad hoc interpreters (family members, untrained staff), especially for consent and education.
      • Qualified interpreters improve accuracy, patient safety, and satisfaction. [18]
      • Document interpreter use in the medical record.
    • Translation of Wound Care Instructions
      • Provide written wound care instructions in the patient’s preferred language.
      • Use plain language and culturally appropriate terms.
      • Include visuals for dressing changes, signs of infection, and when to seek care.
      • Ensure translated materials are professionally reviewed. [19]
    • Addressing Low Health Literacy
      • Assume universal precautions: simplify communication for all patients.
      • Use short sentences, common words, and specific actions (e.g., “change dressing once daily”).
      • Limit education to 2–3 key points per visit.
      • Avoid medical jargon (e.g., use “redness spreading” instead of “erythema”).
    • Teach-Back Method
      • Ask patients to repeat instructions in their own words.
      • Frame as a check of provider communication, not patient knowledge.
      • Re-teach and reassess if understanding is incomplete.
      • Teach-back improves wound care adherence and outcomes. [20]

    For additional details on health literacy, refer to section 'Determining Health Literacy and Literacy' in topic "Patient Education in Wound Care and Hyperbaric Oxygen Therapy".

    LEGAL, ETHICAL, AND REGULATORY CONSIDERATIONS

    Providing culturally and linguistically appropriate services (CLAS) is not only a best practice for quality patient care but also a critical component of legal and ethical compliance within the healthcare system. Federal laws, such as Title VI of the Civil Rights Act, mandate meaningful language access for patients with limited English proficiency (LEP). Adherence to these regulations, alongside core ethical principles like autonomy and beneficence, ensures that wound care services are delivered equitably, respect patient rights, and mitigate the risk of medical error and legal liability stemming from communication failure or discrimination. Table 3 below illustrates selected regulations and ethical principles related to CLAS. For additional details, see topics "Legal Aspects in Wound Care" and "Medical Ethics In Wound Care".

    Table 3. Selected Regulations and Ethical Principles related to Culturally and linguistically appropriate services (CLAS) in Wound Care
    • Title VI of the Civil Rights Act
      • Prohibits discrimination based on national origin, including language.
      • Requires meaningful access to care for patients with limited English proficiency (LEP).
      • Applies to all healthcare organizations receiving federal financial assistance. [21]
    • Language Access Requirements
      • Provide qualified medical interpreters at no cost to the patient.
      • Do not rely on family members or untrained staff except in true emergencies.
      • Ensure translated vital documents (e.g., consent forms, discharge instructions).
      • Applies to Medicare-, Medicaid-, and other federally funded programs. [22]
    • Ethical Principles in Language Access
      • Autonomy: Patients must understand information to make informed decisions.
      • Respect: Language access affirms dignity and cultural identity.
      • Beneficence: Clear communication reduces harm and improves outcomes.
      • Failure to provide language access increases risk of medical errors. [23]
    • Documentation and Informed Consent
      • Document:
        • Patient’s preferred language.
        • Interpreter type (in-person, video, phone) and interpreter ID if available.
        • Use of translated materials.
      • Ensure informed consent is obtained in a language the patient understands.
      • Inadequate documentation may create legal and regulatory risk. [24]

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    Use of WoundReference is subject to the Subscription and License Agreement. ​
    NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

    REFERENCES

    1. U.S. Department of Human and Health Services. Education - Think Cultural Health . 2024;.
    2. The National CLAS Standards. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care .;.
    3. Bowleg L. The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health. American journal of public health. 2012;volume 102(7):1267-73.
    4. World Health Organization. (n.d.).. Social determinants of health .;.
    5. U.S Department of Health and Human Services. (n.d.).. Social determinants of health. Healthy People 2030. .;.
    6. National Health Interview Survey. 14 National Center for Health Statistics. (2019.) Percentage of fair or poor health status for adults aged 18 and over, United States, 2019. .;.
    7. U.S. Department of Health and Human Services. (n.d.).. Discrimination. Healthy People 2030. .;.
    8. Duru OK, Harawa NT, Kermah D, Norris KC et al. Allostatic load burden and racial disparities in mortality. Journal of the National Medical Association. 2012;volume 104(1-2):89-95.
    9. Agency for Healthcare Research and Quality. (2020). 2019 national healthcare quality and disparities report. .;.
    10. Hoffman KM, Trawalter S, Axt JR, Oliver MN et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences of the United States of America. 2016;volume 113(16):4296-301.
    11. Chuck, E., & Assefa, H. (2020, February 8) et al. She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it. NBC News. .;.
    12. Jacobs EA, Rolle I, Ferrans CE, Whitaker EE, Warnecke RB et al. Understanding African Americans' views of the trustworthiness of physicians. Journal of general internal medicine. 2006;volume 21(6):642-7.
    13. Kumagai, Arno K. MD; Lypson, Monica L. MD et al. Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education .;.
    14. Hook, J. N., Davis, D., Owen, J., & DeBlaere, C. (2017) et al. Cultural humility: Engaging diverse identities in therapy. .;.
    15. Melanie Tervalon , Jann Murray-García et al. Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education Journal of Health Care for the Poor and Underserved Johns Hopkins University Press. 1998;volume 9(2):.
    16. Cecile N. Yancu, PhD1*; Deborah F. Farmer, PhD et al. Product or Process: Cultural Competence or Cultural Humility? . 2017;volume 3(1):.
    17. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care. .;.
    18. Agency for Healthcare Research and Quality (AHRQ). Improving Patient Safety Systems for Patients With Limited English Proficiency .;.
    19. Centers for Medicare & Medicaid Services (CMS). Toolkit for Making Written Material Clear and Effective. .;.
    20. Institute for Healthcare Improvement (IHI). Teach-Back: A Tool for Improving Patient–Provider Communication. .;.
    21. U.S. Department of Justice. Title VI of the Civil Rights Act of 1964. .;.
    22. U.S. Department of Health and Human Services, Office for Civil Rights et al. Guidance to Federal Financial Assistance Recipients Regarding Title VI and Language Access .;.
    23. . Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Balogh EP, Miller BT, Ball JR, editors. Washington (DC): National Academies Press (US) . 2015;.
    24. Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS). Revised Appendix A, Interpretive Guidelines for Hospitals, and Appendix W, Interpretive Guidelines for Critical Access Hospitals (CAHs) . 2011;.
    Topic 3165 Version 1.0

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