Section I: Introduction

I. Introduction

A. Project background and objectives

The Health Resources and Services Administration (HRSA) is sponsoring a project to develop a cultural competence measurement profile comprising a conceptual measurement framework and set of measures for gauging cultural competence in health care settings. HRSA has contracted The Lewin Group to conduct this work. The goal of this effort is to contribute to an understanding of how the complex construct of cultural competence can be measured and advance the capacity of organizations to carry out such measurement.

As the Nation’s “Access agency,” HRSA recognizes that cultural competence is an essential component of accessible, responsive, and high quality health services. Ensuring cultural competence is a key strategy in HRSA’s commitment to achieving a goal of providing access to quality health care for all. HRSA also recognizes that a key mechanism for ensuring cultural competence is the ability to measure it for purposes related to developing, monitoring, and evaluating health care services. While the field has made strides in this area, much more needs to be known. Through this project, HRSA hopes to make a contribution to the field by providing a measurement profile that can serve as a building block for future work by HRSA and others interested in culturally competent health service delivery, including consumers, providers, policy makers, and researchers.

The objectives of this project are to: 1) develop a conceptual framework for measuring cultural competence in health care settings; 2) identify specific indicators and measures that can be used to assess cultural competence within health care; and 3) assess the feasibility and practical application of these measures. The following report details a comprehensive review of the cultural competence theoretical and methodological literature. This report is one component of the larger measurement profile project, which involves further development and refinement of the profile through site visits to best practice health care organizations and clinics, as well as discussions with experts in the field.

This literature assessment serves two related purposes. The first is to synthesize and examine the state-of-the-art of measurement of cultural competence, particularly as related to health care, in order to develop a potentially useful resource for the field. In addition, the literature assessment will provide a basis for decisions about the scope, content, and value of the measurement profile to be developed in this project.

B. Organization of the Report

This report begins with a review of how cultural competence has been conceptualized. The identification and discussion of the areas in which cultural competence must be evidenced are presented as critical domains for measuring cultural competence. The report then presents and applies a measurement framework for the identification and review of specific performance indicators and measures of cultural competence that are garnered from the literature. The report identifies key challenges in measuring cultural competence and potential areas for further analysis are discussed. The conclusion section of this report highlights key themes raised throughout the report and presents considerations for next steps. 

An annotated bibliography of the works consulted, which appears at the end of this report, is categorized into the following areas: core models and concepts of cultural competence, assessment tools and evaluative models, performance measures and/or indicators, and program-and condition-specific studies.

Also presented at the end of this report is a matrix of measures and indicators of cultural competence identified from the literature. (Attachment 3) These measures and potential indicators of cultural competence are grouped by domain areas and identified by type of measure.

C. Literature review methodology

The project team conducted a targeted literature review of published and unpublished articles, monographs, and reports identified through several sources, including: a HRSA work-group, which included individuals from a variety of bureaus and offices comprising a subgroup of HRSA’s Cultural Competence Committee; the project’s Technical Expert Panel and interviews with other experts in the field; and bibliographic search engines, including (MEDLINE(R) 1993-2000/December, Help News 154, HealthSTAR 1975-2000/Dec, TGG Health&Wellness DB(SM) 1976-2000/Dec, and Allied and Complementary Medicine 1984-2000/OCT). 

HRSA and The Lewin Group jointly identified several criteria to select the articles and reports included in this review. The goal was to target literature for theoretical and methodological rigor, while maintaining enough flexibility to capture the variety of perspectives on cultural competence and its measurement. Attachment 2 of this report provides a summary of these criteria.

Prepared for:
The Health Resources and Services Administration
September 2001

Prepared by:
The Lewin Group, Inc.

Acknowledgements:
Willine Carr, HRSA Project Officer
Jeanean Willis, HRSA Project Officer