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Section
II: Conceptualizing Cultural
Competence and Identifying
Critical Domains
I.
Conceptualizing Cultural Competence and identifying
critical Domains
Based
on the literature review, this section reports on the current
state of the field in conceptualizing cultural competence
and identifies key domains or areas for measuring cultural
competence. This
section also provides a synthesis of the literature that
provides a basis for each of the domains identified by the
project team. A full annotation of the articles reviewed for this analysis
can be found in the bibliography at the end of this document.
A.
Approaches to conceptualizing cultural competence
Many
health care professionals agree that cultural competence
is a critical factor in providing relevant services to the
nation’s growing culturally and ethnically diverse patient
population.
An extensive body of literature exists that describes
the evolution of cultural competence in the context of health
care.
The following discussion primarily focuses on this
body of work, recognizing that literature outside of the
health care sphere (e.g., social marketing, anthropology,
communication and media, etc.) could also enhance the understanding
of cultural competence in health care.
While many articles addressing the concept of cultural
competence were reviewed, the project team identified five
central works.
The authors of these five works are Cross, T.L.,
Bazron, B.J., and Isaacs, M.R, Campinha-Bacote, J.,
Carballeira, N., Leininger, M., Davidhizar, R., and Giger,
J.N. These works were chosen as seminal literature because
of their scope and substance, their frequent citation in
the literature, and the consensus validation of their ideas
and perspectives in works of many other authors.
The
literature provides health care professionals with several
definitions of cultural competence and numerous methods
for providing culturally competent care.
For the purpose of this review, we use the definition
of cultural competence set forth by Cross, T.L., Bazron,
B.J., Dennis, K.W., Isaac, M.R., and Campinha-Bacote, J.
Cultural competence is “a
set of congruent behaviors, attitudes, and policies that
come together in a system, agency, or among professionals
and enable that system, agency, or those professionals to
work effectively in cross-cultural situations.”
The
literature on cultural competence approaches the issue of
competence in two ways: theoretical and methodological.
For example, Cross, et al. and Campinha-Bacote offer
a theoretical approach in which cultural competence is seen
as a process or continuum whereby an individual’s view of
other cultures transforms from destructive or unaware to
proficient.
Cross, et al. define a set of factors that
must be present in order to progress along the continuum.
There are six possible points along this continuum:
1.
Cultural destructiveness,
2.
Cultural incapacity,
3.
Cultural blindness,
4.
Cultural pre-competence,
5.
Cultural competence, and
6.
Cultural proficiency.
Furthermore,
Cross, et al. describe several conditions that must exist
in order for professionals to move along this continuum.
Professionals must: value diversity, understand their
cultural biases, be conscious of the dynamics that occur
when cultures interact, internalize cultural knowledge,
and develop adaptations to diversity.
Each of these conditions set by Cross, et al. must
function at every level of the health care system in order
for that system to provide culturally competent care.
Similar
to Cross, et al., Campinha-Bacote views cultural competence
as a process, not an endpoint, in which health professionals
continually strive to work within the cultural context of
the patient.
The process requires health care providers “to see
themselves as becoming culturally competent rather than
being culturally competent.”
Although Campinha-Bacote does not define points in
this process of becoming, the author does outline five components
of cultural competence similar to the five essential elements
presented by Cross, et al.
The five components of competence include:
1.
Cultural awareness,
2.
Cultural knowledge,
3.
Cultural skill,
4.
Cultural encounters, and
5.
Cultural desire.
Health
care providers can work on any one of these constructs to
improve the balance of all five, but eventually all five
constructs must be experienced and addressed.
Campinha-Bacote explains that the intersection of
these constructs represents the process of cultural competence,
and as the area of intersection becomes bigger, health care
providers will internalize cultural competence at a deeper
level and provide higher quality care.
Authors
such as Carballeira, Leininger,
and Davidhizar and Giger offer
a more methodologically driven
approach that focuses on the methods
a professional might use in order
to become culturally competent
and provide culturally competent
care.4,
,
These authors typically assume that cultural competence is a
goal that can be reached when
a skill set is learned with the
proper training.
 D-link
Specifically
Carballeira depicts the interaction between a provider and
a client as a cross-cultural exchange of attitudes.7
The author suggests that in a health care setting,
the patient simply reacts to the provider’s “cultural attitude.”
Similar to the Cross, et al. and Campinha-Bacote
continuum models, Carballeira proposes that the provider’s
cultural attitude falls within a range: superiority, incapacity,
universality, and sensitivity, to competence.
Additionally, Carballeira explores the patient’s
reaction to the provider where the client’s reaction ranges
from resistance to accommodation to adaptation.
The author suggests the use of the LIVE & LEARN
model which presents providers with a practical, phased
approach to cross cultural service delivery that respects
client centrality, avoids stereotyping, and leads to the
adoption of mutually acceptable objectives and measures
for changed behavior.
In this model, the acronym “LIVE” stands for Like,
Inquire, Visit, and Experience,
while “LEARN” stands for Listen,
Evaluate, Acknowledge, Recommend,
and Negotiate.
Leininger’s
Sunrise Model provides a method for assessing patients in
order to provide comprehensive and culturally sensitive
care.
Leininger believes that the Western medical model
fails to explore cultural patterns of illness.
The Sunrise Model suggests that the world view and
social structure of the client are important areas to investigate
and can be explored using seven dimensions:
1.
Cultural values and lifeways,
2.
Religious, philosophical, and spiritual beliefs,
3.
Economic factors,
4.
Educational factors,
5.
Technological factors,
6.
Kinship and social ties, and
7.
Political and legal factors.
Health
care professionals must develop the skills, knowledge, and
patience to explore and validate what the patient says and
does. Once
information is obtained for each of the dimensions, health
care professionals can guide patient treatment and interventions.
According to this Sunrise Model, providers should base their
selection of a treatment approach or combination of approaches
on information gathered from the assessment. Leininger suggests
that this guidance can occur in a variety of ways: cultural
care preservation and/or maintenance, cultural care accommodation
and/or negotiation, and cultural care repatterning and/or
restructuring.
Davidhizar
and Giger also present a transcultural assessment model
to assist health care professionals in assessing patients
from diverse cultures that focuses on six factors:
1.
Communication,
2.
Space,
3.
Time,
4.
Social organization,
5.
Environmental control, and
6.
Biological variations.
According
to Davidhizar and Giger, health care professionals should
receive training on how to use these factors to assess the
health beliefs and practices that may have a significant
impact on how an individual responds to treatment and patient
education. Using
this assessment model will assist health care professionals
in providing care that is sensitive and tailored to the
needs of culturally diverse individuals.
The various
approaches to conceptualizing cultural competence identified
in the literature stress the importance of viewing cultural
competence as a dynamic process involving continual progression
and involvement of all levels of the health care system.
The literature identifies essential elements and conditions
that must be present in the health care system in order
to support cultural competence. These essential elements
will provide a basis for identifying domains for measuring
cultural competence, as discussed in the Section II. B of
this report.
B.
Critical domains for measuring
cultural competence
 D-link
The
conceptual literature discussed in the previous section
and other literature reviewed later in this document suggest
that cultural competence in health care settings must be
evidenced or manifested in a broad range of spheres or areas.
The project team has preliminarily identified nine
such areas that are potentially important to the development
of a measurement profile for cultural competence in health
care settings. These areas are referred to here as domains,
and include:
1.
Values and attitudes,
2.
Cultural sensitivity,
3.
Communication,
4.
Policies and procedures,
5.
Training and staff development,
6.
Facility characteristics, capacity, and infrastructure,
7.
Intervention and treatment model features,
8.
Family and community participation, and
9.
Monitoring, evaluation and research.
Within
these global domains, many specific subjects or topic
areas were identified as characterizing the domain and
forming the particular focus or substantive content for
which indicators and measures might be identified and developed.
These topic areas are discussed in Section II. C
of this report. In
this section of the report, the nine domains are defined
with regard to providers’/health care organizations’ cultural
competence and discussed with respect to the domains’ linkage
to the key conceptual literature.
Domain
1: Values and
attitudes
Values
and attitudes refer to the set of beliefs and mindsets possessed
by providers, administrative staff, health care organizations
and others involved in service delivery.
The discussion of values and attitudes in the conceptual
literature is intertwined with discussions of cultural sensitivity
(see below). The
conceptual literature emphasizes training, assessment, and
cultural encounters in order for providers to increase the
awareness of the values and attitudes they bring to the
consumer-provider interaction.
Cultural encounters also increase providers’ ability
to understand those that consumers bring with regard to
health, medical treatment, and authority.
In other words, provider values and attitudes toward
other cultures can change through cross-cultural interactions
with clients and by developing knowledge about and adaptation
to this diversity.
Leininger’s theory requires health care professionals
to evaluate, acknowledge, and develop respect for the cultural
differences. This
can be accomplished through active listening, open-ended
questions, and a nonjudgmental attitude toward the differences
that are encountered.
Carballeira stresses the importance of the provider’s
“cultural attitude” and describes a range of attitudes,
from “superiority” to “competence.”
At the “competence” level, the provider can respect
client centrality, avoid stereotyping, and adopt mutually
acceptable objectives and measures for changed behavior.
Domain
2: Cultural
sensitivity
Cultural
sensitivity generally refers to heightened awareness and
complements several other domains, most notably communication.
While values and attitudes refer to the beliefs held by health care professionals,
cultural sensitivity refers to heightened knowledge of the
needs of the client. Often, cultural sensitivity
manifests itself in a provider’s ability to accurately interpret
and respond to non-verbal or other cultural cues or in the
way in which health care organizations provide information
to their clients. This sensitivity can lead to the behavioral
adaptations needed for cultural competence. For
example, Cross, et al. and Campinha-Bacote both view cultural
competence as a continuum.
As a person moves along the continuum, their values
and attitudes undergo a transformation from a state of ignorance
to one of competence.
However it is also possible for an individual to
be culturally aware, and not change behaviors to become
culturally competent.
Domain
3: Communication
Communication
encompasses a wide range of activities, both oral and written,
that describe the flow and exchange of information among
those involved in the provision and receipt of care, including
interpersonal exchanges and exchanges between individuals
and organizations.
Cultural factors affect the consumer-provider communication. Cultural competence leads to actions creating concordance in
communication styles and increasing the availability and
accessibility of language services (e.g., interpretation
and translation) to improve communication.
Improved communication can lead to increased consumer
satisfaction as well as an improved understanding of and
compliance with diagnoses and treatment regimens. From a
conceptual perspective, Davidhizar
and Giger focus heavily on communication as a key tool for
improving cultural competence in their theory of transcultural
assessment. Providers
must assess the patient’s communication style to learn about
cultural-specific cues that are used.
For example, an understanding of these communication
cues can assist the provider in explaining procedures and
instructions.
Domain
4: Policies
and procedures
Policies
and procedures refer to the programmatic and planning vehicles
through which organizations can facilitate the provision
of culturally competent care.
Specifically, this includes mechanisms, such as conflict
resolution processes and hiring procedures, as well as other
devices that operate primarily in managed care settings,
such as the breadth of provider networks and types of incentive
systems. Cross, et al.
discuss policies and procedures in the context of their
continuum of care.
As an agency or professional moves toward cultural
competence, they begin to understand the interplay between
policy and practice and are committed to policies that enhance
services to diverse clientele.
Those that are culturally blind (a mid-point along
the continuum) may believe that they are implementing culturally
competent policies when, in fact, their policies may be
discriminatory and ultimately restrict access to services.
When an agency or professional reaches cultural proficiency,
policies are flexible and culturally impartial.
Domain
5: Training
and staff development
Training
and staff development concentrates on how to provide health
care professionals the knowledge and skills required to
supply culturally competent care.
An understanding of providers’ individual skill and
knowledge level represents a starting point from which to
develop programs and curricula to develop cultural competence
among health care providers and other staff in health care
settings. Conceptually, the literature often presents training and professional
development in the context of interventions and treatment.
However, the domain also addresses the training that
happens in academic institutions. Campinha-Bacote,
Carballeira, Leininger and Davidhizar and Giger agree that
health professionals should be trained to collect relevant
cultural data when conducting health histories and assessments.
Although training and staff development potentially
constitutes a topic area within policies and procedures,
numerous training efforts profiled in the literature as
well as the conceptual emphasis on its importance led to
its categorization as a separate domain.
Domain
6: Facility characteristics, capacity, and infrastructure
Facility
characteristics, capacity, and infrastructure refer to issues
related to the access and availability of care and the environment
in which it is provided, including location, hours of operation,
physical resources, and information systems.
Often, these issues influence consumers’ experiences
in a health care delivery setting and can hamper their capacity
to access it. Cross,
et al. address this issue when discussing the influence
of an organization’s infrastructure on its ability to be
culturally competent.
An organization in seeking to become culturally competent
can address the needs of different cultures by developing
service models that are adapted to the cultural-specific
needs of the population.
Domain
7: Intervention and treatment model features
Interventions
and treatment model features focus on aspects of patient
evaluation, diagnosis, treatment, and referral services.
These can include how traditional healing beliefs
interrelate with the Western medical model, ethnopharmacology,
inclusive decision-making, care
coordination, and, in a managed care context, health benefit
design. Conceptually,
Campinha-Bacote, Carballeira, Leininger and Davidhizar and
Giger discuss how culturally competent evaluation of consumers
can assist providers in planning interventions and treatments. Basing diagnoses on a cultural assessment that is sensitive
to the cultural needs and beliefs of the patient and sharing
it with consumers in a culturally sensitive manner can contribute
to consumers’ increased understanding of diagnoses and treatment.
This increased understanding is a step towards improving
compliance with a treatment regimen and addressing consumers’
health concerns. To
truly address issues of intervention and treatment providers
must understand the epidemiological profile of the client
base.
Domain
8: Family and
community participation
Family
and community participation refers to family centered, family
focused, and family-oriented care that recognizes the important
role of the family and the larger community in the provision
of health care. Community
participation in assessments and community outreach efforts
represent means for providers to develop an understanding
of consumers’ cultural backgrounds and support structures
and to include these perspectives into policy planning and
development and other activities. The extent to which the
health care system considers and incorporates input from
a broader unit than the direct client influences the degree
to which consumers and providers engage in culturally competent
discourse. Both
Leininger and Davidhizar and Giger stress that a cultural
assessment of a patient should explore the social organization
or kinship and social ties of the patient.
This includes involving the family and/or community
members when appropriate.
Domain
9: Monitoring,
evaluation and research
Efforts
to become culturally competent include monitoring and evaluating
current efforts in order to assess the extent to which cultural
competence is present, is maintained, and contributes to
desired results with respect to health and health care.
The spectrum of efforts includes assessing organizations,
services, and consumer needs and satisfaction. In addition
to evaluation and monitoring, organizations and individuals
can pursue research activities designed to create and disseminate
new knowledge on cultural competence.
From a conceptual perspective, Campinha-Bacote suggests
that providers should research and obtain a sound educational
foundation about the various world views of different cultures.
Developing a knowledge base helps build cultural
awareness which can result in cultural competence.
Exhibit
I
provides a summary of the ideas related to the domains as
found in the key conceptual literature and demonstrates
the degree of congruence within the field.
It also portrays to some extent the degree of overlap
among the nine domains.
As noted earlier, these nine domains represent the
broad spheres or areas in which cultural competence should
be evidenced or manifested in culturally competent health
care settings. Within these domains, specific topics or
subjects further characterize the domains and provide clues
to what might be included in a measurement profile. In Section
II. C of the report and in Attachment 3, the domains and topic areas are discussed in light of
a review of an extensive and wide-ranging set of documents
and publications. (See Annotated Bibliography.)
Exhibit I
Comparison
of Key Literature (Authors) by the
Critical Domains of Cultural Competence
|
Author |
Domains
Identified by Lewin |
|
Values
and Attitudes |
Cultural
Sensitivity |
Communication |
Policies
and Procedures |
Training
and Staff Development
|
Intervention
and Treatment Model Features |
Facility
Characteristics, Capacity
and Infrastructure |
Family
and Community Participation
|
Monitoring,
Evaluation and Research |
| Cross |
Cross, et al. View cultural
competence as a continuum
whereby professional’s views
of and attitudes toward
other cultures change from
being destructive to proficient.
Health care professionals
move along this continuum
by building a base of cultural
knowledge and developing
adaptations to diversity. |
|
Agencies
or professionals that are
culturally blind may believe
that they are implementing
culturally competent policies
and procedures when in actuality
their policies may be discriminatory
and restrict access to services. |
|
As health
care professionals move
along the continuum toward
cultural proficiency, the
care they provide becomes
sensitive to cultural differences
and the quality of care
improves. |
Culturally competent agencies
or professionals seek to
provide services that are
accessible to many different
cultures. They have
a variety of service model
adaptations in order to
better meet the needs of
minority populations. |
|
|
| Campinha-Bacote |
Cultural competence is
a process whereby providers
gradually build cultural
awareness, knowledge and
skills which result in changing
attitudes toward different
cultures and, eventually,
cultural competence.
Providers can progress toward
cultural competence by having
encounters with other cultures
and drawing on knowledge
and skills to adapt to the
situation. |
|
|
Professionals
should be trained to collect
relevant cultural data when
conducting health
histories and physical assessments. |
Once
all five factors are internalized,
providers can experience
cultural competence and
are able to provide quality
care. |
|
|
It is important to obtain
a sound educational foundation
concerning the various world
views of different cultures.
This involves research and
training. |
| Carballeira |
Carballeira’s theory explores
the importance of the provider’s
attitude toward different
cultures and how culturally
competent attitudes can
improve the quality of patient
care. As providers
develop attitudes that are
more sensitive to different
beliefs and understandings
of health and illness, they
gain the ability to better
assess the patient and provide
more appropriate care. |
|
|
Providers should be trained
to use the LIVE and LEARN
patient assessment models
in order to avoid stereotyping,
and provide competent care
that leads to changed patient
behavior. This patient assessment
model helps providers to
provide quality care because
treatment is planned in
a culturally sensitive way
based on a cultural assessment
such that patients understand
treatment and change their
behavior to adhere to the
treatment. |
|
|
|
| Davidhizar
and Giger |
|
Culturally sensitive encounters
include an assessment that
helps providers to develop
awareness and knowledge
of the needs of the particular
patient. Included
is an assessment of the
patient’s communication
style and the verbal and
nonverbal cues used by different
cultures. An understanding
of these communication cues
assists a provider in adequately
explaining procedures and
instructions. |
|
Health care professionals
should be trained in the
transcultural assessment
model in order to assess
the health and well-being
of patients from different
cultures. Information
collected from this assessment
helps to inform the treatment
that is given and ultimately
improves the quality of
care. |
|
The
authors stress the importance
of understanding the social
organization of different
cultures. Health care
providers should be sensitive
to the family’s role in
patient care and encourage
participation if appropriate. |
|
| Leininger |
Leininger’s
assessment requires health
care professionals to evaluate
acknowledge, and respect
cultural differences in
world view and social structure. |
|
|
|
Leininger suggests that
staff be trained in the
use of an assessment model
to explore the world view
and social structure of
patients from different
cultures. Health care
professionals must develop
the skills, knowledge and
patience to complete the
assessment so that the results
can be used to guide patient
treatment and interventions.
Leininger sets up a formal
framework for how results
can be used to inform treatment
based on three modalities. |
The patients’ response
to the facility should be
noted and the patient should
be made comfortable within
the space whenever possible. |
The
assessment should explore
the kinship and social ties
of the patients and involve
family and/or religious
leaders when appropriate. |
|
 D-link
C.
Topic areas addressed by
the critical domains of cultural
competence
Having
examined the domains and their grounding in the conceptual
literature, this section presents a synthesis of the remaining
literature-based evidence supporting each domain.
It highlights specific behaviors, activities, and
issues that address the question of cultural competence.
Domain
1: Values and
attitudes
The
beliefs and mindsets of organizations, professionals, and
consumers influence direct care encounters, shaping the
interaction between the consumer and the provider, the provider’s
delivery of care, and the way in which consumers perceive
care.
These
values can manifest themselves at different levels. At the individual level, the literature discusses the importance
of acknowledging and respecting other cultures and the role
of culture in health care.
One particular topic area of emphasis is that of
provider diversity.
Beyond the individual consumer and provider, the
literature highlights the importance of incorporating principles
related to cultural competence in organizational missions,
visions, and goals.
This represents an area of overlap with the domain
of policies and procedures.
Awareness
and acceptance of culture and its impact on how care is
delivered and received is an essential element in a culturally
competent program ,
,
,
,
,
,
,
,
and applies to both consumers and providers.
Cultural perceptions influence when a symptom is
defined as a health problem and the severity of the problem
and whether to seek advice.
-
Behui,
et al. argue that consumers’ unique sets of beliefs
about the causation of their change in function and
emotional experience influences their determination
of who they perceive to be appropriate healers.
-
Perez-Stable,
et al. discuss how the cultural concept of fatalismo
(fatalism) in Latino culture may lead some Latinos to
be less likely to change behavior to reduce risk or
seek care.
Providers
who are aware of cultural beliefs also have more effective
communication with consumers,14 highlighting the interconnectedness of the domains of cultural
competence.
-
Oomen
and Owen examine how to identify and treat Type II diabetes
among Latinas and recommend that understanding consumers’
perceptions of diabetes and its treatment would lead
to a more culturally sensitive method of diagnoses and
treatment.
-
Crandall,
et al. discuss the importance of socially responsible
values in the provider workforce by examining attitudes
of medical students and how they change.
Awareness
and acceptance can take various forms, from acknowledgment
to respect. Identification and recognition of the differences
between cultures and how they shape interactions represents
a first step towards accommodating and adapting care to
respect those differences.
Carballeira posits that shifts in cultural attitudes
of providers and consumers can lead to improved results,
and includes elements of that shift in the “LIVE & LEARN”
model. In this
model, changes in consumers’ reactions would shift from
resistance-accommodation-adaptation while changes in providers’
reactions would progress along a continuum of superiority-incapacity-universality-sensitivity-competence.7
Ultimately, conveying respect during encounters where differences
of values exist remains challenging because manifestations
of respect depend on culturally-specific norms of interaction. Furthermore,
the impact of cultural value differences is not limited
to race and ethnicity alone but extends to socioeconomic
status and power dynamics that differ by race and ethnicity.25
In
addition to awareness, acknowledgment, respect, and acceptance
of cultural values and differences, several articles discuss
the need to emphasize the value of diversity and other values
that promote healthy outcomes for underrepresented groups.
17,
25
Instilling a positive view of diversity differs from,
but can co-exist with, targeted recruitment and retention
efforts by health care organizations discussed under the
policies and procedure domain. Promoting diversity as a value becomes important as these efforts
require time and resources to progress.
At
an organizational level, the literature stresses the importance
of creating mission and vision statements that articulate
an organization’s principles and rationale related to providing
culturally competent health care services. These goals and
objectives can also manifest themselves in program announcements,
policies, and requests for proposals.
Domain
2: Cultural
sensitivity
Cultural
sensitivity generally refers to heightened awareness and
complements several other domains, most notably communication.
Lister defines cultural sensitivity as regard for
a consumer’s beliefs, values, and practices within a cultural
context and awareness of how a provider’s background may
influence professional practice.16
Cultural sensitivity also refers to some of the less readily
quantifiable aspects of care with regard to culture. For instance, Hennessy and Friesen discovered that Mexican-Americans
were highly concerned with the “caring” with which service
was delivered, more than the technical proficiency of the
care.
Non-verbal
communication, visual representation, and non-translated
culturally-sensitive materials are examples derived from
the literature of cultural sensitivity related to communication.
9,
,
,
Though these topic areas also align with the domain
of communication, their evolution from a finely tuned understanding
of culture-specific needs and preferences beyond language
needs merits their inclusion here.
-
Salimbene
discusses how providers and consumers use a “cultural
filter” to process a host of information, including
facial expressions, body language, and behavior, in
provider-consumer interaction.15
-
Wright,
et al. study similar issues about non-verbal communication
in relation to critical care patients making end-of-life
decisions across a range of racial and ethnic groups.
They observe how non-verbal cues are often critical
in decision-making and how misunderstandings of these
cues can lead to decisions around which little agreement
exists.
-
Yancey
and Waldlen describe the success of using Spanish-language
videotapes in increasing breast and cervical cancer
screening among Latinas and African-American women.
These videotapes included relevant cultural dynamics,
varied production elements with entertainment value
(e.g., music), information comprehensible to an audience
with little formal education, and a minimally didactic
presentation.
-
Guidry,
et al. analyze culturally sensitive printed cancer education
materials targeted at African Americans, gauge their
educational value
and discuss the need for cultural sensitivity to encompass
the culture-specific needs and preferences of those
populations for whom English is the primary language
of communication.
Domain
3: Communication
Communication
encompasses a wide range of activities that describe the
flow and exchange of information among those involved in
the provision and receipt of care.
This focuses primarily on interpersonal exchanges
between consumers and individual providers and the exchange
that occurs between consumers and health care delivery organizations.
The literature discusses a number of concerns regarding
communication and how cultural factors may affect the consumer-provider
communication,
including issues related to communication style, language
services available to consumers, and language-concordant
capacity of providers.
Consumers
and providers each possess independent styles of communication.
There is evidence that having a sufficient number
of administrative and provider staff competent in negotiating
the communication styles of racial and ethnic groups seeking
services can help minimize the need for interpreters and
other language services.10
Peer education and testimonials are other mechanisms to communicate
across different styles.
-
In
studying how to increase breast and cervical cancer
screening rates for African-American, Latina, Chinese,
and Vietnamese women, Pasick, et al. discuss the importance
of peer education and testimonials.
Specifically, they examine different videos and
printed brochures employed by a variety of clinics to
determine the preferences of specific populations in
terms of what information is important for them, how
that information should be crafted into a message, and
the different media preferences of the various populations.
-
DiClemente
and Wingwood conducted the first randomized controlled
trial of community-based HIV sexual risk reduction for
economically disadvantaged young adult African American
women and found that those who participated in peer
education sessions on a variety of topics demonstrated
significant improvement in some risk factors relative
to their control group counterparts.
Open
communication between the provider, consumer, and the consumer’s
family is also critical to gaining understanding between
providers and consumers with different communication styles.
-
Oomen
and Owen, in examining how to identify and treat Type
II diabetes among Latinas, suggest that providers ask
direct questions on follow up visits regarding treatment
adherence, barriers to compliance, and possible solutions.21
Language
services for those consumers with limited English proficiency
or for whom English is not the primary language is of growing
importance in making treatment decisions and ensuring appropriate
care. ,
These include the provision and appropriate use of interpreters
and translated materials, for educational and administrative
purposes. The
Culturally and Linguistically Appropriate Services (CLAS)
standards stress the importance of interpreters in consumers’
interactions with the health care delivery system.,
The availability of interpreter services that is
timely and of high quality is often a concern, and standards
for this vary.,
Family and friends are not adequate substitutes for
trained interpreters who demonstrate bilingual proficiency
and receive training that includes the skills and ethics
of interpreting and knowledge in both the terms and concepts
relevant to clinical or non-clinical encounters.
-
Baker,
et al. examine the use of interpreters in emergency
departments, assessing how often they are used and who
usually interprets and studies consumer and provider
perceptions of the appropriateness of their use based
on respective language capabilities.
They find that regardless of provider competence
in the consumer’s language of preference, consumers
tend to prefer the use of interpreters, except when
the consumer is more comfortable in English than another
language.
-
Randall-David
and Pasick, et al. discuss some of the difficulties
in selecting an interpreter and stress that providers
require training and knowledge in order to work with
one effectively. ,
In
addition to oral language services, the presence of translated
materials helps meet the needs of limited English proficiency
consumers. ,
Translated materials can include patient education resources
and administrative paper work, including consent forms,
and should be translated into primary language of communities
served. ,
,
,
,
The translation should minimize the use of medical
and professional jargon and be tailored for the appropriate
racial and ethnic sub-populations.
It is critical to test translated materials prior
to widespread use.46
Also, direct service providers should gauge the literacy
rate of the target population.
High illiteracy would merit more use of interpreter
services or other visual representations vis-à-vis printed
materials.
-
The
examination of educational interventions to increase
cervical cancer screening among non-white elderly by
White, et al. reveals that educational interventions
increase the awareness and need for routine Pap testing
among the elderly but leave consumers’ questions about
the most efficient way to obtain this care unanswered.
These findings highlight how providers need to
be aware of their clients’ informational needs and level
of comprehension.
Another
area widely discussed in the literature relates to language
concordance and the linguistic capacity of direct service
providers. The
language ability of the consumer is important to consider
in order to understand the need for interpreter services
and can be tracked through patient records.Additionally, providers’ reliance on their
own language skills is often sub-optimal.
Not being able to rely on the usual linguistic cues
may disrupt the degree to which physicians can obtain informed
consent and how physicians assess and evaluate symptoms
and result in misdiagnosis.
-
Woloshin,
et al. suggest bilingual phrase sheets for staff and
consumers as one way to facilitate communication.
-
Fluency
examinations and credentialing represent more rigorous
methods to improve the skill of providers who assume
interpretation roles.
Domain
4: Policies
and procedures
Several
articles highlight the importance
of policy in ensuring that consumers
receive appropriate services and
helping provider organizations
to institutionalize cultural knowledge.25,
,
,
Policy development can
occur in planning and governance,
as well as creating
provider incentives and
grievance and conflict resolution
processes.
Defining the breadth of
plan and provider networks and
staffing also becomes relevant
in a managed care setting.
A precursor of policy development
is a process to incorporate cultural
competence language on policy
statements, including strategic
plans and contract requirements.Caution
should be exercised in policy
development as this can serve
as a barrier to care.
Agencies or professionals
that are “culturally blind” may
believe that they are implementing
culturally competent policies
and procedures when their policies
may discriminate against different
racial and ethnic groups and restrict
access to services.
Policy
changes made at a system level can begin with changes to
planning and governance procedures.
Planning and governance represents a means for organizations
to incorporate cultural values and priorities in service
delivery and to move from mission to implementation.46
-
The
CLAS standards discuss including strategic goals, plans,
policies, and procedures as part of a comprehensive
management strategy.
-
Other
recommendations in the field for health care delivery
organizations include the creation of a cultural competence
plan that includes defined steps for its integration
at every level of organizational planning and the related
policy or procedural changes needed.
The
processes to recruit and retain
clinical and non-clinical staff
for provider networks also represent
policy areas in which health care
delivery organizations can choose
to act. Several
authors view recruitment, retention,
and development of staff with
cultural knowledge and skills
as an element of a culturally
competent program.8,
,
-
The
CLAS standards recommend developing and implementing
a strategy to recruit, retain, and promote a qualified,
diverse, and culturally competent administrative, clinical,
and support staff that represents the racial, ethnic,
and other communities being served.,
-
Several
sources suggest that developing specific job descriptions
for staff who work with consumers from diverse cultural
groups or posting position descriptions and personnel/performance
measures that include skill sets related to linguistic
competence can also attract personnel with cultural
skills and encourage professional development among
current staff.,
53
In
the context of managed care, hiring processes may affect
network breadth and thus face increased scrutiny.
-
Rosenbaum,
et al. discuss how managed care plans can employ policies
that limit the care available to underserved populations
and cite areas of concern such as definition of service
areas, criteria for membership in provider networks,
and segregation of networks for publicly-insured consumers.
Creating
incentives for providers and grievance and conflict resolution
processes for consumers is another important policy area
that can influence the cultural competence efforts of an
organization. Sanctions
and incentives can encourage culturally competent behavior,
measuring issues like culture-related complaints and grievance,
and should decrease over time as situations change.In
terms of grievance and conflict resolution, the CLAS standards
suggest developing institutional structures and procedures
to address cross-cultural ethical and legal conflicts in
health care delivery and complaints or grievances by patients
and staff about unfair, culturally insensitive, or discriminatory
treatment, or difficulty accessing or denial of services.
Domain
5: Training
and staff development
Training
and staff development refer to the ways in which provider
organizations can develop cultural competence among health
care providers and other staff involved in the provision
of care. Articles
discuss the importance of training providers in culturally
and linguistically appropriate communication and identify
measures and standards to ensure that this type of training
as well as training in cultural knowledge occurs.
In
designing cultural competence training, federal efforts
to understand the standards for culturally and linguistically
appropriate services discuss how health providers and health
service agencies should require and arrange for ongoing
education and training for administrative, clinical and
support staff.On-going training is integral to progressing
towards cultural competence and must be supported by structured
opportunities to learn.
These opportunities can be based on a developed framework
for cultural diversity educational programs.,
,
,
57
Curricula
should be broad based and explore the differences not only
among ethnic groups but also among various social groupings
defined according to gender, generation, lifestyle, and
socioeconomic class..
Self-assessment
can play a valuable role in the process of working towards
cultural competence. Self-assessment tools develop the capacity
of the care provider to recognize that one’s own culture
and cultural perceptions play a role in the consumer-provider
exchange. This in turn should lead to a better understanding
of other cultures and the rewards of providing culturally
competent care. The training curriculum should assist the
caregiver in this process by providing tools for self-assessment.8,
,
The
literature presents another method for achieving “self discovery”
in training through structured opportunities to work with
other cultures and ethnicities.
-
Barton
and Brown find that students working with migrant health
communities reported deepening respect for cultural
minority groups, were able to identify the differences
in cultural norms, and recognized the rewards gained
in their transcultural experience.57
Domain
6: Facility
characteristics, capacity, and infrastructure
Providers
should seek
to provide services that are accessible to many different
cultures in a location and environment that is accessible
and supported by information systems that can track cultural
data.,
,
Accessibility
extends to the physical environment in which care is provided
and how it is culturally perceived.
-
Pasick,
et al. in their study of the role of culture in health
promotion focused on cancer screening for African-American,
Latina, Chinese, and Vietnamese women find that many
medical care settings and the location of community
activities influence the degree to which women obtained
care.
-
Wright,
et al. consider the impact of physical space and surroundings
in end-of-life decision making and address the how the
cultural interpretation of space can affect these decisions.
Information
systems that allow providers to collect and track cultural
data are also critical to facilitating health care delivery
organizations’ efforts to encourage cultural competence.
These data systems should include the capacity to link records
by ethnicity in a timely way that allows tracking of patients
and protects confidentiality.
-
Looking
at a selection of states, the Texas Department of Health
concludes that one lesson in implementing cultural competence
is the capacity to gather information and use that information
for long-term planning.25
-
The
CLAS standards also discuss how health care providers
should use a variety of methods to collect and utilize
accurate demographic, cultural, epidemiological and
clinical outcome data to become informed about ethnic/cultural
needs, resources and the assets of the community.
Domain
7: Intervention
and treatment model features
Interventions
and treatment model features range from culturally and linguistically
competent evaluation, diagnosis, treatment, and referral
services to interactions with traditional healing belief
and inclusive decision-making.
Other treatment model features that influence whether
consumers and providers interact in a culturally competent
manner include care coordination and health benefit design.,
Coordination of services and case management at the
community level is an area providers can use to address
the needs of diverse populations, particularly to promote
continuity of care.53
Many
authors suggest that cultural competence is linked to quality
of care and enhances it.,
,
7,
Multiple
organizations and research efforts specify the need for
culturally and linguistically competent evaluation, diagnosis,
treatment, and referral services.,
,
Full
and accurate patient histories are of particular interest
and several authors introduce models and protocols for diagnosis
that allow providers to take medical histories and conduct
an initial assessment in a way that accounts for cultural,
sociological, psychological, and biological factors, including
the level of the consumer’s acculturation.,
,
7,
,
,
Several
authors suggest the establishment of guidelines on a range
of clinical issues, such as triage and assessment, care
planning, treatment services, and case management.These guidelines should avoid stereotyping
through superficial master of culture-specific characteristics
but should rather build on evidence-based evaluation of
cultural information identified through literature reviews
and interactions with consumers.
Some authors suggest that providers have specialized
assessment procedures for different racial and ethnic groups
and include cultural factors in assessment protocols.
-
In
their study of racial variation in cardiac procedure
use and survival, Peterson, et al. find that African-American
males treated at Veterans Affairs Medical Centers were
less likely than their white counterparts to undergo
selected cardiac procedures.
Despite this difference in treatment received,
African-American males experienced significantly higher
survival rates than the white counterparts.
However, the authors focus on the issue of whether
standards of care differ by racial and ethnic group,
regardless of outcome.
The authors suggest several reasons for the differences
in treatment, including differences in severity and
consumer preferences but also differences in how providers
may weigh the risk and benefit of invasive procedures
differently for African-Americans than for whites.
-
Todd,
et al. study analgesic use in emergency departments
and find that ethnicity was the strongest predictor
of the lack of use of analgesics.
The authors suggest that providers may encounter
difficulty recognizing pain in culturally different
patients or that the presence of other decision-makers
influence the provider’s decision to administer pain
relief.
-
Oomen
and Owen, in looking at why Latinas with Type II diabetes
often do not receive appropriate care, suggest that
providers identify specific economic, social, familial
and religious barriers to treatment adherence and modify
treatment regimens accordingly.
Including
providers from multiple disciplines in care teams can facilitate
interaction with ethnically diverse communities as well
as assist in efforts to reach out to traditional healers.64
Some authors emphasize the importance of cultural concordance
between consumers and providers, such that consumers would
receive services directly from either competent bicultural/bilingual
personnel or personnel representing their own racial and
ethnic group.
-
Goiceochea-Balbona
discusses how an interdisciplinary group was able to
respond to an HIV crisis in a rural community through
bringing together the strengths of the team’s respective
disciplines and working with indigenous providers.
-
The
Moy and Bartman study of 1987 NMES data reveals that
minority patients were more than four times more likely
to receive care from non-white physicians than non-Hispanic
white patients and that individuals who received care
from non-white physicians were more likely to report
worse health.
Obtaining
an understanding of whether consumers are using traditional
healers or other non-conventional care is important, particularly
in the context of managed care where access to such services
is often restricted.8,
,
Some
authors encourage providers to reach out to traditional
healers and encourage consumers to embrace traditional healing.
,
-
In
1990, almost nine out of ten respondents to a survey
conducted by Eisenberg reported seeing a non-conventional
provider without the recommendation of their medical
provider.
-
Faculty
at the Medical College of Pennsylvania instituted a
four-hour session for second year medical students that
introduced guidelines for eliciting information from
and working with patients with traditional health beliefs
and practices, citing the need to understand the prevalence
of traditional beliefs and practices in their community.
-
The
Massachusetts Chronic Disease Improvement Network suggests
that providers recognize, accommodate, and integrate
folk illnesses with biomedical treatments and also recommends
working closely with decision-makers to identify, suggest,
and explain biomedical alternatives to traditional practices.
Input
into decision-making regarding treatment represents another
topic area related to intervention and treatment.
Specifically, the literature’s focus on involving
the culturally appropriate decision-makers often concentrates
on involving families.Establishing
agreement on the parameters of care can create an understanding
of the diagnoses and securing compliance with treatment
regimens.,
This
topic also relates to the domain of family and community
participation but is included here to illustrate the importance
of being inclusive in making treatment decisions.
Domain
8: Family and
community participation
Culturally
diverse family participation at policy and program levels
enhances the ability of providers and health care organizations
to serve in a culturally competent manner. ,
42,
64
Treatment should incorporate familial and
community strengths in addition to individual strengths,
and appropriate agency resources.
-
Davidhizar
and Giger recognize the unique role of families and
the differences in social organization in different
cultures. They
stress that providers should be sensitive to the family’s
role in patient care and encourage participation if
appropriate.
-
Finley
recognizes the role of families in caregiving and discusses
the use of support models for families that build upon
the strengths of families with diverse racial and ethnic
backgrounds.
-
HRSA’s
Maternal and Child Health Bureau suggests steps that
health care delivery organizations can take to involve
families more intimately in the care process consisting
of including extended family in family/provider meetings
and conferences and arranging meetings that are convenient
and comfortable for families, particularly parents.53
-
Blackhall,
et al. summarize a study that examined differences in
attitudes regarding informing consumers of a cancer
diagnosis among various racial and ethnic groups. The authors find that although some groups believe the consumer
should be aware of the diagnosis, others rely on the
family to make the decision as to whether and where
to inform the consumer of the diagnosis and treatment
option.
-
In
the context of managed care, Starfield, et al. discover
that consumers reported on a survey of satisfaction
with primary care services better “family-centeredness”
when they received services at a facility characterized
by high degrees of limitation on physician autonomy
or by capitation as compared to receiving services at
a facility characterized by a low degrees of limitation
on physician autonomy and non-capitated reimbursement.
Reaching
out to cultural groups can enhance providers’ understanding
of consumers’ needs while developing their understanding
of the location of the group, gaps in service, and barriers
to care.42
In
assessing ways to improve the linguistic competence of primary
care delivery systems, the National Center for Cultural
Competence regards support of community outreach initiatives
to persons with limited English proficiency as one way to
gauge progress.Developing
relationships with key persons in the community helps providers
to learn about the cultural values, beliefs, and practices
of the community and provides a vehicle for community members
to participate in the health care delivery system.
-
Goiceochea-Balbona
discusses how reaching out to key traditional healers
was a critical component in the success of an effort
to respond to an HIV crisis in a rural community.
-
The
CLAS standards include recommendations to use formal
mechanisms for involving communities and consumers in
service delivery design and execution, including planning,
policy-making, operations, evaluation, training, and,
as appropriate, treatment planning.
Domain
9: Monitoring, evaluation and research
Monitoring
and evaluation are critical to becoming culturally competent
because it highlights areas of progress and needed improvement.
This includes organizational assessment and an evaluation
of consumer satisfaction and perception and use of services.
In addition to evaluation, creating and disseminating new
knowledge on cultural competence represents another arena
for issues related to cultural competence.
Organizational
assessment tools help both individual health practitioners
and plan managers to better understand the process of delivering
health care to culturally and linguistically diverse communities.The literature implies that prior
to conducting an organizational assessment, the organization
should conduct a community needs assessment to be knowledgeable
about the community it serves.25
Additional evaluations should span multiple
stakeholders and integrate measures of access,
satisfaction, quality and outcome for culturally and linguistically
appropriate services into internal audits and performance
improvement programs.25
-
The
CLAS standards suggest that organizations and providers
should prepare an annual report documenting the organizations’
progress with cultural competence, including information
on programs, staffing, and resources.
Analysis
of consumer satisfaction and evaluation of services are
also integral in providing culturally competent care.This feedback is particularly important
in managed care organizations and other organizations that
monitor provider behavior.
Possible methodologies include focus groups and a
patient survey system to measure quality improvement.
The evaluation of specific services should also include
a discussion of how culture affects health care.,
Exhibit
II summarizes
the references to the domains and sample topic areas by
type of literature (e.g., core models and concepts, assessment
tools and evaluative models, and program- and condition-specific
studies).
This
targeted review of the literature provides evidence for
the nine domains of cultural competence and the topic areas
within each of them.
In the remainder of the report, these topic areas
and domains are discussed with a focus on a measurement
framework and potential indicators and measures.
Exhibit
II
Domains
and Sample Topic Areas by Type
of Literature
|
Topic Area |
Core models and concepts
(24 articles) |
Assessment tools and evaluative
models
(40 articles) |
Program
evaluation and condition-specific
studies
(62 articles) |
|
Acknowledges,
respects |
X |
X |
X |
|
Diversity |
|
X |
|
|
Mission,
vision |
|
X |
|
|
Non-verbal
communication |
X |
X |
X |
|
Visual
representation |
|
X |
X |
|
Culturally
sensitive encounters |
X |
X |
X |
|
Communication
styles |
X |
X |
X |
|
Interpreter |
|
X |
X |
|
Translated
materials |
|
X |
X |
|
Linguistically
competent organization |
|
X |
X |
|
Linguistic
capacity of provider |
|
X |
X |
|
Language
ability, oral and written,
of consumer |
|
|
X |
|
Provide
information, education |
|
X |
X |
|
Administration
and staff should be able
to translate, cultural brokering |
|
X |
|
|
Choice
of health plan network |
|
X |
|
|
Choice
of providers, provider network |
|
X |
|
|
Grievance
and conflict resolution |
|
X |
|
|
Planning
and governance |
|
X |
|
|
Adequate
financing |
|
X |
|
|
Staff
hiring, recruitment |
|
X |
X |
|
Incentive
systems |
|
|
X |
|
Policy
development |
X |
X |
X |
|
Training
and professional development |
X |
|
X |
|
New
staff orientations |
|
|
|
|
Structured
opportunities to learn |
X |
|
X |
|
Bilingual
training |
|
|
X |
|
Assessment
of the knowledge and skills/
attitudes of the provider |
X |
X |
X |
|
Cultural
knowledge |
X |
X |
X |
|
Knowledge
of community needs |
|
|
X |
|
Provider
preparation |
X |
X |
X |
|
Available
and accessible services |
X |
X |
X |
|
Physical
environment, materials,
and resources |
|
X |
X |
|
Information
system |
|
|
X |
|
Diagnosis,
care planning, referral
and treatment |
X |
X |
X |
|
Culturally
competent services |
|
X |
|
|
Cultural
competence and quality of
care |
X |
X |
|
|
Culturally
competent health benefit
design |
|
X |
|
|
Culturally
competent treatment plan |
|
X |
|
|
Culturally
competent care |
X |
X |
|
|
Input
into treatment decision
and service quality |
|
X |
X |
|
Use
of medicines according to
cultural belief, ethnopharmacology |
|
X |
X |
|
Use
of traditional healers,
healing methods |
X |
X |
X |
|
Use
of interdisciplinary teams |
|
|
X |
|
Family
centered care |
X |
X |
X |
|
Community
and consumer participation |
X |
X |
X |
|
Family
focus, family-oriented,
recognition of the uniqueness
of the role of the family |
X |
X |
X |
|
Coalition-building |
|
|
X |
|
Community
outreach |
|
X |
X |
|
Consumer
or member satisfaction and
feedback |
X |
X |
X |
|
Community
needs assessment |
X |
X |
X |
|
Organizational
Assessment |
|
X |
|
|
Evaluation
of health plans |
|
X |
|
|
Evaluation
of services |
|
X |
|
|
Evaluation
of provider |
|
X |
|
|
|
|
