Rural Cultural Competence and Limited English Proficiency

Culturally and linguistically competent health and human services are essential for America’s diverse populations. Cultural competence describes the ability of service delivery systems to provide quality assistance to clients with diverse values, beliefs, or traditions, including tailoring delivery to meet their social, cultural, and linguistic needs. It is a set of behaviors, attitudes, and policies that come together in an agency or among professionals enabling them to work effectively in cross–cultural situations.

Limited English proficiency (LEP) refers to the restricted ability to read, speak, write, or understand English by individuals who do not speak English as their primary language. These individuals may be entitled language assistance with respect to a particular type or service, benefit, or encounter. Collectively, cultural competence and LEP address the necessity to understand and respond effectively to the cultural and linguistic needs among people of different nationalities, ethnicities, and cultures.


For information on cultural competency programs and training
National Center for Cultural Competency (NCCC)
Telephone: 800.788.2066/202.687.5384

For publications, articles, and database searches on minority health topics; for a list of cultural competence trainers
DHHS Office of Minority Health Resource Center (OMHRC)
Telephone: 800.444.6472
Information services available in both English and Spanish

For cultural competence and medical interpreter training and referral
Cross Cultural Health Care Program (CCHCP)
270 So. Hanford St., Suite 208 Seattle, WA 98134
Telephone: 206.860.0329
Email: (Training); (Resource Center)

For information on or to file a complaint regarding discrimination on the basis of race, color, national origin, or sex in programs or activities of federally-assisted entities
U.S. Department of Justice
Civil Rights Division
Coordination and Review Section - NYA
950 Pennsylvania Avenue, N.W
Washington, DC 20530
Title VI Hotline: 888-TITLE-06 (888.848.5306) (Voice/TDD)

There are more organizations related to Cultural Competence and Limited English Proficiency in the organizations section.

Frequently Asked Questions

What is cultural competence and why is it important in rural areas?

Many definitions of cultural competence have been put forward, but probably the most widely accepted are the following:

Cultural and linguistic competence is a set of coinciding behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations. “Culture” refers to integrated patterns of human behavior that include the language, thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups. “Competence” implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented by patients and their communities.

Stated more simply, cultural competence is the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes.

Also, cultural competence can be defined as services that are sensitive and responsive to cultural differences whereby caregivers are aware of the impact of culture and possess the skills to help provide services that respond appropriately to a person's unique cultural differences, including race and ethnicity, national origin, religion, age, gender, sexual orientation, or physical disability.

As the U.S. rural population becomes more diverse, health care providers are serving more patients with backgrounds, beliefs, and language skills that are different from their own. According to an Association of Schools of Public Health and Association of American Medical Colleges report, Cultural Competence Education for Students in Medicine and Public Health, culturally competent care:

  • Reduces health disparities
  • Improves health care access
  • Increases quality of care
  • Enhances the likelihood that care is relevant to the populations being served
  • Improves health outcomes

For a more thorough understanding of cultural competence, the National Standards on Culturally and Linguistically Appropriate Services (CLAS) offers federal guidance on providing culturally and linguistically competent care.

Where can I find information and resources to provide cultural competence training for staff development?

There are several agencies and organizations that will provide the resources and/or training to implement cultural competence within an organization. Think Cultural Health provides free online and accredited culturally competency continuing education programs for physicians, pharmacists, nurses, and social workers. TrainingFinder Real-time Affiliate Integrated Network or provides free online training on cultural competency skills that includes health literacy and Limited English Proficiency. This training module can be taken for credit and non-credit and is appropriate for health care professionals.

  • National Center for Cultural Competence (NCCC)
    Located at Georgetown University. Contributes a variety of services for health and mental health programs wishing to design, implement, and evaluate culturally and linguistically competent service delivery systems. Services include a resource database, tools for self-assessment, technical assistance, consultation and training events.
  • Office of Minority Health (OMH)
    Established by the U.S. Department of Health and Human Services (HHS). Develops health policies and programs to eliminate health disparities and also serves as a national resource and referral service on minority health issues.
  • Office of Minority Health Resource Center (OMHRC)
    Collects and distributes information on a wide variety of health topics. Website is available in Spanish and consumer health resources can be found in several different languages.
  • Cross Cultural Health Care Program (CCHCP)
    Through a combination of cultural competency trainings, medical interpreter trainings and assessment tools, serves as a bridge between communities and health care institutions to ensure full access to quality health care that is culturally and linguistically appropriate.

Who is a Limited English Proficient (LEP) individual?

Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English can be limited English proficient, or "LEP." These individuals may be entitled language assistance with respect to a particular type or service, benefit, or encounter.

What are the federal laws concerning language access for LEP individuals?

Federal laws applicable to language access include Title VI of the Civil Rights Act of 1964, and the Title VI regulations, prohibiting discrimination based on national origin, and Executive Order 13166 issued in 2000. Many individual federal programs, states, and localities also have provisions requiring language services for LEP individuals.

The Department of Health and Human Services Office of Minority Health has developed the enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care along with the implementation guide:    National Standards for CLAS in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. These standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations to provide effective, equitable, understandable and respectful quality of care and services responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

What is Executive Order 13166?

An Executive Order is an order given by the President to federal agencies. The “LEP” Executive Order 13166, available from the U.S. Department of Justice, titled Improving Access to Services for Persons with Limited English Proficiency, states that people who are LEP should have meaningful access to federally conducted and federally funded programs and activities.

Executive Order 13166 requires all agencies that provide federal financial assistance to issue guidance on how recipients of that assistance can take reasonable steps to provide meaningful access consistent with Title VI and the Title VI regulations. The Order also requires that federal agencies create plans for ensuring that their own activities also provide meaningful access for persons who are LEP.

What federal activities are covered by the Executive Order?

The Executive Order covers all "federally conducted programs and activities." Anything a federal agency does falls within the scope of federally conducted programs or activities. All of the federal agencies are responsible for developing and implementing "federally conducted plans" to ensure that persons who are LEP have meaningful access to all the federal programs and activities.

How do these laws affect limited English proficient children in school settings?

Federal law requires programs that educate children with limited English proficiency to be based on a sound educational theory; adequately supported, with effective staff and resources to ensure a positive outcome; and be periodically evaluated and/or revised.

Where can I find resources for implementing a program that improves access to services for persons with limited English proficiency?

The Limited English Proficiency( is a Federal interagency website that promotes a positive and cooperative understanding of the importance of language access. acts as a clearinghouse, providing and linking to information, tools, and technical assistance regarding Limited English Proficiency and language services for federal agencies, recipients of federal funds, users of federal programs and federally assisted programs.

Health Resources and Services Administration produced the Health Care Language Services Implementation Guide, a guide to help healthcare organizations implement effective language access services to meet the needs of their patients with limited English proficiency (LEP). In addition the Agency for Healthcare Research and Quality provides two, in both English and Spanish to measure an individual's reading comprehension in a medical context. These tools can be used for research, clinical or program planning purposes.

Who will enforce the LEP rules?

Most federal agencies have an office that is responsible for enforcing Title VI of the Civil Rights Act. To the extent that a recipient's actions are inconsistent with their obligations under Title VI, then such agencies will take the necessary corrective steps. The Coordination and Compliance Section of the Civil Rights Division of the Department of Justice has taken the lead in coordinating and implementing this Executive Order.

What skills are needed by the workforce to provide culturally competent care?

According to the 2012 AAMC/ASPH report, cultural competencies consist can be summarized into three domain areas:

  • Knowledge (Cognitive Competencies) – Understanding cultural diversity and the influence of culture on health outcomes
  • Skills (Practice Competencies) – Integrating cultural perspectives into treatment/interventions, communicating in a culturally competent manner with patients, and incorporating culture as a key component of patient history
  • Attitudes (Values/Beliefs Competencies) – Appreciating how cultural competence contributes to the practice of medicine, assessing the impact of one’s own culture on care and service, and realizing that cultural competence involves lifelong learning

Full descriptions of these summaries are available in the AAMC/ASPH report.