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Health Resources and Services Administration Study On Measuring Cultural Competence in Health Care Delivery Settings


Section IV: Conclusion

I. Conclusion

A. Review of findings from the literature

This literature review report reflects an analysis of over 120 works in the field of cultural competence in health care and forms the basis for the development of a measurement profile for cultural competence in health care delivery settings. The literature reviewed includes seminal works that illuminate core concepts of cultural competence, as well as other literature examining specific assessment protocols or program and condition-specific issues. In analyzing this literature, The Lewin Group identified a preliminary set of nine domains for measuring cultural competence that emerged as core clusters from the array of theoretical and methodological concepts and approaches presented in the literature.

For each domain, specific indicators and measures were also identified from the literature. In reviewing the indicators and measures identified in the literature and their linkage with particular domains and topic areas, there was evidence of differing representation of measures by type of measure and across various domains and topic areas. In terms of measure type, the majority of measures in the literature can be classified as process oriented, with far fewer falling into the category of outcome/impact. The abundance of process measures and paucity of outcome/impact measures may be due to a variety of factors, including a lack of infrastructure to support data collection on outcomes. Process measures typically reflect the operational functioning of an organization and, hence, may represent data already being collected by an organization. The collection of outcome/impact measures often requires more sophisticated data collection techniques, additional resources, and may be impeded by privacy and confidentiality concerns. The lack of outcome/impact measures may also be due to the difficulty in parsing out the contribution of cultural competence to ultimate outcomes relative to other factors.

Measures were identified for almost all of the domains, with the exception of cultural sensitivity. Cultural sensitivity, though stressed in the core models and methods literature, was the least represented in the collection of health system measures. It is unclear to what extent this represents an actual gap in the field of study or points to overlap in how measures are constructed. It may be the case that the domain of cultural sensitivity and its attendant topic areas are imbedded or captured adequately through other domains.

In general, the review and analysis of the literature highlighted critical elements to be measured in health care delivery setting and potential areas for measurement. However, while the literature contains many examples of standards and guidelines that can be translated into performance measures, as well as tools that can be used in assessing cultural competence in various health care delivery settings, the literature containing tested and validated measures of cultural competence is limited. This lack of validated and broadly applied measures represents a significant challenge for the further development of a measurement profile.

B.     Implications for developing a measurement profile

While the literature review provided support for what constitutes the critical elements (i.e., domains) of cultural competence, in order to further refine and develop a measurement profile of cultural competence, the field must move beyond conceptualizing cultural competence to applying and testing actual measures of cultural competence in real-world settings. Before an empirically-tested measurement profile can be developed, several challenges need to be considered, both generic to measurement and specific to measuring cultural competence.

Measurement Challenges Specific to Cultural Competence
  • Fluid and multi-faceted nature of culture and cultural competence: Culture is typically characterized as a monolithic, unitary phenomenon that remains stable over time and homogenous within different social groups. However, in actuality both culture and cultural competence are fluid and dynamic constructs and processes. This may pose a dilemma for measuring cultural competence given the requisite concreteness of measurement and the fluid nature of cultural competence. 
  • Complexity of culture and cultural competence: Along with the issue of fluidity is the need to consider the complex nature of culture and cultural competence. Culture and cultural competence as multi-faceted constructs will require a measurement approach that captures not only fluidity, but also its relationship to and interaction with an individual, organization, health care delivery system, and society.
  • Attribution: Cultural competence is an essential component of a larger set of variables important for improving access, eliminating health disparities or impacting other types of outcomes. Due to the multiplicity of factors that influence these outcomes, it becomes difficult to parse out the contribution of cultural competence in the larger context of other factors.

General Measurement Challenges
  • Organization’s appreciation of the value of measurement: One of the key challenges to measurement is garnering the organizational will to pursue activities around measurement. Organizations must first recognize the value of measurement and view it as an integral component of their operational functioning. Without “buy-in” from every level of an organization as to the importance of measurement, forward momentum may be stalled and derailed.
  • Data availability and feasibility: While a measure may be deemed important for measurement, without an existing data source further progress is delayed. A corollary data challenge in measurement is the issue of feasibility. Data collection may not be feasible due to the burden associated with additional staffing requirements and available financial resources. 
  • Baseline data: Related to the issue of data availability and feasibility is the lack of adequate baseline data to support measurement. Baseline data and an adequate assessment of the current environment are necessary for setting targets and assessing change and impact. Without adequate baseline data, the timeline for proceeding with measurement may be delayed until additional resources are identified to collect it.
  • Capacity of health care delivery organizations for measurement: Many organizations are not equipped to invest in measurement. Organizations may lack the infrastructure needed to engage in measurement activities, such as information technology, dedicated staff, record keeping, etc. It may be necessary for organizations to do an internal scan of their capacity to engage in measurement efforts and either identify, direct or re-direct the necessary resources.
  • Instrumentation and tools: The evolution of more sophisticated measures must coincide with the evolution of appropriate instrumentation and tools. Existing measurement tools may not be able to capture the nuances of specific measures. Various tools such as surveys and interviews have inherent limitations that may impact their usefulness for measuring difficult concepts within cultural competence.
  • Short term versus longitudinal measurement issues: In assessing the value of process versus outcome types of measures, many prefer outcome measures because of their potential to demonstrate direct and concrete impacts of various activities. However, while outcome measures may be preferred, they are much more difficult to measure and their impact may not be readily identifiable in the short term. The use of outcome measures may require longer time horizons to demonstrate impact.

The purpose of this literature review report and the overall HRSA project is to serve as a building block for advancing the practical understanding of how to measure cultural competence in health care settings. An important next step includes refining the identified domains and identifying areas where domains and topic areas could be collapsed. Important next steps toward assessing the feasibility and practical application of potential measures include identifying: a limited core set of indicators/measures; ways to translate and apply these measures in health care settings; potential data sources and approaches for obtaining information on these indicators and measures; existing and needed instruments and tools for gathering information on the identified indicators and measures of cultural competence; and the infrastructure necessary to support measuring cultural competence in health care delivery settings. Gathering information from health care delivery settings on the appropriateness and feasibility of the measurement profile will advance the science of measuring cultural competence in health care delivery settings by addressing the question, "How do we know cultural competence when we see it?"