The successes and limitations of the existing impact literature on cultural competence point to substantial opportunities for future research in each of the identified categories. Using both descriptive and quantitative approaches, this research can further illuminate the details of cultural competence interventions as well as specific impacts on health care delivery outcomes.
The major task of this project was to propose future research directions in the area of cultural competence and health care delivery and health outcomes. By analyzing the literature, the project team was able to identify areas where the current research was weak or lacking, and suggest areas and questions for further exploration. These efforts were buttressed by the discussions and recommendations of the RAC, both during the April 2001 RAC meeting and in subsequent reviews of the research agenda drafts.
The major product of this endeavor is the group of research agendas found at http://www.omhrc.gov. Each research agenda contains a definition of the category, a brief synthesis of findings from the literature, key research questions, and a discussion of methodological and policy considerations influencing future research for that area.
The research agendas reflect that some of the topic areas were backed by a greater body of literature and/or generated more interest from RAC members. The extensive agenda developed for the language assistance interventions category mirrors its prominence among both health care providers and policymakers. It is also the agenda best supported by previous research related to outcomes. Additional topics generating significant interest included cultural competence education and training, and racial, ethnic and linguistic concordance. The topic of organizational supports generated a broad list of questions, although the majority of these focused on their effect on the processes of health care delivery and not on health outcomes.
It is interesting to note that as stakeholder interest and investment in implementing certain interventions increases (e.g., interpreter services, hiring for diversity, cultural competence training), so too does the demand for concrete linkages between an intervention and outcomes, especially cost-related benefits.
Conversely, there are many providers who are willing to undertake these interventions without "proof of value," perhaps simply due to consumer demand for such interventions or because the face value of the intervention is obvious. Many RAC members pointed out that, methodological and funding challenges aside, the importance of outcomes research on cultural competence interventions should not be overstated, given that many cultural competence interventions have already been implemented despite the lack of rigorously conducted, definitive outcomes studies.
The following highlights of the Cultural Competence Research Agenda are organized into three groups of cultural competence interventions:
A complete list of research questions can be found in Part 2 of the full report.
Among the activities listed under Category A, cultural competence education and training generates considerable interest among providers, educators, and policymakers for its potential impact on improving the patient- provider relationship when cultural differences exist. While the descriptive literature on this topic is extensive, studies that examine the impact of training on either trainees and patients is more limited. Some connections are made with increases in levels of cultural knowledge, attitudes and awareness, and improvements in communication skills among trainees. Few studies examined the impact of training on health care delivery, patient behavior change, or health outcomes. The topic and the literature, however, were sufficient to inspire a substantial number of future research questions. These include questions that seek to better understand and define the intervention related to:
Another category of questions seeks to measure the impact of training on both providers and patients. These include questions on:
The topic of racial, ethnic and linguistic concordance among providers and patients has already generated considerable research interest. The literature suggests that some patients from multicultural groups prefer to seek care from providers of their own race, ethnicity, or language group, and that such concordance appeared to have a positive impact on appropriate service utilization, treatment participation, and receipt of some services. However, the literature on the effects of positive outcomes in utilization was not shown to translate into improvements in health outcomes. Many health care organizations and policymakers have pursued diversification of the workforce as a way of increasing patient-provider concordance, although others are skeptical, given the demographic difficulties of achieving this goal across-the-board. Nevertheless, ongoing research in this area can also be of considerable value for what it illuminates about crosscultural health care encounters. Key research questions focus on:
Both these topics have already been extensively researched, although not necessarily with a specific focus on the effect of the culturally competent aspect of the interventions. Studies suggest linkages between the intervention and increases in health-care-related knowledge, self-care practices, screening rates, and decreases in risk behaviors. Both types of interventions could benefit from further research in the following areas:
The literature on the impact of language barriers and language assistance interventions is both substantial and promising with respect to outcomes. Studies show that language barriers have a demonstrable negative impact on communication, satisfaction, and appropriate health care utilization. A growing body of literature suggests that language assistance interventions such as oral interpretation can have a positive effect on patient satisfaction and comprehension, and improvements on health care delivery measures such as increases in the amount of time spent with patients, reduction in diagnostic testing disparities among English-speaking patients versus limited English proficient (LEP) patients, higher clinic return rates, and increases in primary care services utilization.
The research agenda on this topic is divided into four areas around which to structure future research efforts on language assistance:
The research agenda identifies eight types of organizational supports for cultural competence. These are primarily management activities not expected to have a direct impact on health outcomes, but intended to improve health care delivery to culturally diverse populations.
To date, both descriptive and process-related outcomes research on these activities is very limited. However, a number of research questions were identified that would better define these interventions and investigate potential links between them and improved organizational efficiency. They include research related to:
While there is a high level of interest in the results of research on cultural competence interventions, the RAC identified several methodological challenges to conducting such research. These include lack of:
An additional challenge is the large sample size that is required to prove that cultural competence interventions are more effective than similar interventions that are not designed to be culturally competent.
The RAC also identified various factors that impede the funding and publication of cultural competence research. RAC members thought that funders and journal reviewers tended to lack familiarity with the impact of language and culture on health care delivery and viewed cultural competence research as marginal and/or high risk. This was thought to make some funders unwilling to expend the amounts of money necessary to show linkages between cultural competence interventions and health outcomes, and journals unwilling to accept manuscripts. Researchers, in turn, may therefore consider cultural competence studies to be a high risk undertaking.
These challenges, as well as the RAC's suggestions for addressing them, are discussed in further detail in Part 3 of the full report.
Brach, C., and Fraser, I. (2000). Can cultural competency reduce racial and ethnic disparities? A review and conceptual model. Med Care Res Rev 57(Suppl 1):181-217.
U.S. Department of Health and Human Services Office of the Secretary. (2000). National standards on culturally and linguistically appropriate services (CLAS) in health care. Federal Register 65(247):80865-79.
Current as of August 2004
Internet Citation:
Fortier JP, Bishop D. Setting the Agenda for Research on Cultural Competence in Health Care. Brach C, editor. August 2004. Office of Minority Health and Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/cultural.htm
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