Attachment
1: Annotated Bibliography
Core Models and Methods
Baker C (1997). Cultural relativism
and cultural diversity: Implications for
nursing practice. Advances
in Nursing Science, 20(1), 3-9.
This article examines the doctrine of
cultural relativism in nursing practices. Cultural
relativism is defined as the perspective
that the behaviors of individuals should
be judged only from the context of their
own cultural system. The terms refer to
the use of one’s own culture as
the starting point to judge other cultures
and to the assumption that one’s
own culture is superior to other cultures. The
article examines the dilemmas faced by
nurses in making judgments in cross-cultural
situations and suggests drawing on the
hermeneutic approach as a philosophy for
cultural encounters. The hermeneutic approach
deals with how one person comes to understand
the actions, words, or any other meaningful
product of another person. At the
heart of the hermeneutic perspective is
constructive communication across cultures.
Brink PJ (1999). Transcultural versus
cross-cultural. Journal of
Transcultural Nursing, 10(1),
7.
The article is a short discussion of
the terms transcultural and cross-cultural.
It defines transcultural as the belief
in concepts that transcend cultural boundaries. In
contrast, the author places cross-cultural
in the context of anthropological research
that compares and contrasts cultural groups
with each other.
Campinha-Bacote J (1994). The
process of cultural competence in health
care: A culturally competent model of
care. Perfect Printing Press. Wyoming,
OH.
Campinha-Bacote presents a culturally
competent model of care with four components
on a continuum: (1) cultural awareness,
(2) cultural knowledge, (3) cultural skill
and (4) cultural encounters. Cultural
awareness is defined as having cultural
sensitivity and avoiding cultural biases. Cultural
knowledge is defined as the care provider
understanding the cultural would view
and theoretical/conceptual framework of
the patient. Cultural skill is defined
as the provider having developed the skill-set
to access an individual’s background
and formulate a treatment plan that is
culturally relevant. Cultural encounters
are the processes which allow the health
care provider to directly engage in cultural
interaction with clients from culturally
diverse backgrounds. Additionally
the article provides a checklist of the
“Six A’s for Culturally Responsive
Services” as a as keys to providing
access of services to underserved and
culturally/ ethnically diverse populations. The
six A’s are: (1) available, (2)
accessible, (3) affordable, (4) acceptable,
(5) appropriate, and (6) adoptable.
Campinha-Bacote J (1999). A model
and instrument for addressing cultural
competence in health care. Journal
of Nursing Education, 38(5),
203-207.
This article presents the author’s
Inventory to Assess the Process of Cultural
Competence (IAPCC) among healthcare professionals,
an instrument that measures the constructs
of cultural awareness, cultural knowledge,
cultural skill, and cultural encounters
among health care professionals. The IAPCC
is a self-administered survey that uses
a 4-point Likert scale to score 20 different
items. These 20 items address each
of the four constructs. The full
instrument is not included.
Carballeira N (1997). The LIVE and LEARN
model for cultural competent family services.
Continuum, 17(1), 7-12.
The author applies a model of cross-cultural
attitudes to shed light on what happens
whenever a provider and a client from
different cultures meet. The author
suggests that whenever the provider manifests
a cultural attitude, the client exhibits
some reaction. The model of cross-cultural
attitudes and client reactions fall in
a range from superiority – incapacity
– universality – sensitivity
– to competence, whereas the client
reactions range from resistance –
accommodation – to adaptation. The
author proposes the LIVE & LEARN model
which stands for: Like- Inquire –
Visit – Experience and Listen –
Evaluate – Acknowledge – Recommend
– Negotiate. The model 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.
Cross TL, Bazron BJ, Dennis KW, Isaacs
MR (1999). Toward a culturally
competent system of care, volumes 1 and
2. National Institute of
Mental Health, Child and Adolescent Service
System Program (CASSP) Technical Assistance
Center, Georgetown University Child Development
Center. Washington, DC.
This monograph outlines a philosophical
framework for developing and implementing
a service delivery system that provides
services in a culturally appropriate way
in order to meet the needs of culturally
and racially diverse groups. The
authors developed a comprehensive cultural
competence model that can be used to assist
health care professionals to work effectively
in cross-cultural situations. The
monograph sets forth a six point cultural
competence continuum and, outlines the
five essential elements that contribute
to a system’s or agency’s
ability to become more culturally competent,
and identifies a set of underlying values
that must be present in a culturally competent
system of care. In addition, the
authors provide some practical ideas for
improving service delivery at the policymaking,
administrative, practitioner, and consumer
level.
Klein A, Marie-Martinez R, Lacerino-Paquet
N (1998). Background paper
for a national assessment of linguistically
and culturally appropriate services in
managed care organizations serving racially
and ethnically diverse communities. Prepared
by Mathematica Policy Research, Inc. for
the U.S. Department of Health and Human
Services.
This article is a review of the current
literature that defines and describes
the nature and extent of linguistic and
cultural appropriateness in health care
and that links such services to patient
and health outcomes. The paper provides
a series of definitions for linguistically
appropriate services, a discussion of
the alternative language used for addressing
the concept of cultural competence, and
addresses the different service models
of culturally appropriate care.
Jones M, Bond M, Cason CL (1998). Where
does culture fit in outcomes management? Journal
of Nursing Care Quality, 13(1),
41-51.
The authors describe the concept of cultural
competence and ways in which culture is
important to the delivery of culturally
competent care. The authors propose
strategies for developing a culturally
competent work force; drawing lessons
from on ongoing projects in the United
States and the fields of clinical enthography
and anthropological research.
Leininger M (1993). Towards conceptualization
of transcultural health care systems: concepts
and a model. Journal of Transcultural
Nursing, 4(2), 32-40.
The Sunrise Model is a comprehensive
guide for nurses to use in conducting
a cultural care assessment. The model
is based on six domains: (1) culture values
and lifeways; (2) religious, philosophical,
and spiritual beliefs; (3) economic factors;
(4) educational factors’ technological
factors; (5) kinship and social ties;
and (6) political and legal factors. It
also describes three modalities that can
guide nursing interventions so as to provide
culturally appropriate care: (1) cultural
care preservation and/or maintenance;
(2) cultural care accommodation and/or
negotiation; and (3) cultural care re-patterning
or restructuring. Not all three modalities
may be necessary to achieve cultural competent
care.
Office of Minority Health (1999). Assuring
cultural competence in health care: Recommendations
for national standards and outcomes-focused
research agenda. Recommended
Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health
Care Services. Prepared for the U.S. Department
of Health and Human Services. Washington,
DC.
This report responds to the need to develop
consensus and standards regarding what
constitutes cultural or linguistic competence
in health care service delivery. This
report outlines a set of 14 standards
for use by various stakeholders, including
providers, policymakers, accreditation
and credentialing agencies, purchasers,
patients, advocates, educators and the
health care community in general. The
expectation is that the standards will
provide guidance to providers on how to
provide culturally competent care and
provide policymakers and consumers with
the tools to evaluate and assess whether
a provider is delivering culturally competent
care. The recommended standards were developed
with input from a national advisory committee
of policymakers, health care providers,
and researchers. The process used in developing
the standards included the formulation
of research questions and a review of
technical and policy literature to identify
categories of cultural competence. A content
analysis of the literature was conducted
which identified two thematic clusters
corresponding to (1) linguistic competence
(i.e., language access, interpreter and
translation services) and (2) cultural
competence (i.e., patient, staff and organizational
cultural diversity management). An initial
list of 21 draft standards was consolidated
to 14 standards. The standards relate
to a variety of areas, including policies
and organizational structures, consumer
involvement, training and education of
staff, and the provision of interpretation
services. Along with recommended national
standards, the report also outlines a
research agenda for relating the standards
to outcomes.
Pachter LM (1994). Culture and clinical
care: folk illness beliefs and behaviors
and their implications for health care
delivery. JAMA, 271(9),
690-694.
This article presents an approach to
evaluation of patient-held beliefs and
behaviors that may not be concordant with
those of medical doctors. Most clinical
encounters can be analyzed as an interaction
between the “culture of medicine”
and the “culture of patients.” These
two groups have different beliefs, attitudes,
and knowledge; physicians and patients
often have different ways of conceptualizing
a sickness episode. Illnesses that
do not fit into any biomedical disease
category are often called “folk
illnesses”. The authors present
several reasons for health care providers
to know about folk illnesses and suggest
that clinicians need to become aware of
commonly held folk beliefs, assess the
likelihood of a patient acting on those
beliefs, and arrive at a way to negotiate
between the belief systems.
Pachter LM (1993). Folk illnesses:
methodological considerations. Medical
Anthropology, 15, 103-107.
This paper suggests that methodologies
to study the concepts and beliefs behind
illness are becoming increasingly sophisticated. Brief
explanations of different methodologies
cover exploration of the relationship
between individual informant responses
and underlying cultural beliefs; cross-cultural
variation in folk-illness beliefs; and
analysis of the interface between folk-illnesses
and biomedicine. The author emphasizes
that researchers need to constantly explore
new methodologies when studying folk illnesses.
Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite
RL (1999). Cultural sensitivity in
public health: defined and demystified. Ethnicity
and Disease, 9(1), 10-21. Review.
This article describes various concepts
that are related to cultural competence
and draws from sociological and linguistics
theory to delineate between two levels
of cultural competence (surface and deep). In
examining how to implement interventions,
the authors suggest using focus groups
and pre-testing.
Roberson MR, Kelley JH (1996). Using
Orem’s theory in transcultural settings:
a critique. Nursing Forum,
31(3), 22-28.
This article presents a critical analysis
of Orem’s Self Care Deficit Theory
of Nursing for use with culturally diverse
populations. The article applies
the theory to examples from multiple international
communities, including two examples of
communities in the United States (Navajo
and Puerto Rican). The authors state
the limitations of Orem’s theory
lie in the failure to include a discussion
of how culture impacts health care, of
what specific knowledge base is required
to perform a cultural assessment, and
of what needs to be incorporated into
a cultural assessment.
Shapiro J, Lenahan P (1996). Family
Medicine in a culturally diverse world:
a solution oriented approach to common
cross-cultural problems and medical encounters. Family
Medicine, 28, 149-155.
This article identifies general strategies
that can be applied by medical residents
when approaching cross-cultural encounters. The
authors caution against using the traditional
“universalistic perspective,”
whereby cultural differences are all but
ignored and interpretations and interventions
inconsistent with a patient’s belief
system are imposed on the patient. Instead,
the authors explore the “culture-specific”
model where residents begin to develop
efficient, solution-oriented ways of using
cross-cultural principles to guide patient-physician
interactions. The authors caution
against indulging in a simplistic “cultural
elements” approach whereby residents
are encouraged to become familiar with
a vast array of cultural variation. Instead,
the authors suggest: (1) evidence-based
evaluation of cultural information whereby
residents identify particular cultural
constructs that have clear behavioral/social
implications; and (2) inductive models
of learning whereby the patient, rather
than theory, is the starting point for
discovery and residents observe patient
behavior and form conclusions that apply
to the patient.
Smith LS (1998 Spring). Concept
analysis: cultural competence. Journal
of Cultural Diversity, 5(1),
4-11.
This article examines the concept of
cultural competence and attempts to clarify
the term as used in health care literature
that explores the race-culture comparative
paradigm. The author describes various
components of cultural competence including
the events, ideas, conditions, and behavior
that must occur for cultural competence
to occur, and the consequences of cultural
competence. The importance of developing
methods for measuring cultural competence
and the creation of empirically based
standards for cultural competence are
discussed.
Shumaker RP (1998). Multicultural
needs bring on new opportunities. AORN
Journal, 68(5), 744-746.
This is an editorial exploring the need
for understanding transcultural care. In
this article cultural competence is defined
as the ability to deal with individuals
on different levels, ranging from a transcultural
assessment to identifying factors such
as religious views or folk cures that
may influence a patients behavior when
ill.
Tirado M (1998 December). Monitoring
the managed care of culturally and linguistically
diverse populations. Health Resources
and Services Organization. The National
Clearinghouse for Primary Care Information
, Washington DC.
This study develops culturally sensitive
self-assessment tools which both individual
health practitioners and plan managers
can use to better understand the process
of delivering health care to culturally
and linguistically diverse communities. The
tools were tested by a group of mental
health care professionals to determine
the relevance of the instruments in a
variety of health care settings. With
the collaboration of these groups, the
professionals discussed the organizational
challenges managed care plans face in
seeking to address the needs of limited
and non-English speaking members systematically.
The study promotes “customized care”
efforts that promote an individualized
approach to caring for plan members and
for supporting the professional staff
assigned to serve them.
West EA (1993). The cultural bridge
model. Nursing Outlook,
41(5), 229-234.
The authors explore the application of
the cultural bridge model to providing
nursing care to Native American Indians. The
model is based on the concept of mutual
respect and builds on the idea of maintaining
cultural differences and uniqueness while
having a meaningful relationship with
people of differing cultures.
Assessment Tools and Evaluative
Models [1]
Behui K, Bhugra D (1997). Cross-cultural
competencies in the psychiatric assessment. Journal
of Hospital Medicine, 57(10),
492-496.
This article outlines the essential features
in contemporary psychiatric practice to
which one must attend when patient and
professionals do not share the same culture.
The authors draw upon Kleinman’s
explanatory model that argues that patients
have a unique set of beliefs about the
causation of their change in function
and emotional experience, and this determines
who they think are appropriate care givers
for the healing process.
Bravo M, Canino GJ, Rubio-Stipec M, Woodbury-Farina
M (1991). A cross-cultural adaptation
of a psychiatric epidemiology instrument:
the diagnostic interview schedule’s
adaptation in Puerto Rico. Culture
Medicine and Psychiatry, 15(1),
1-18.
This article illustrates the application
of a comprehensive cross-cultural adaptation
model of the Diagnostic Interview Schedule
(DIS) to both the translation into Spanish
and the adaptation to a population of
Puerto Ricans.
Browne AJ (1997). A concept analysis
of respect applying the hybrid model in
cross-cultural settings. Western
Journal of Nursing Research,
19(6), 762-780.
The article deconstructs “respect”
as a concept in the domain of nursing
using the hybrid model of concept development,
illustrated with examples from two different
cross-cultural settings. The authors point
out that conveying respect during cross-cultural
interactions, and to marginalized or disadvantaged
patients, maybe be particularly challenging
specifically because manifestations of
respect may be dependent on culturally
specific norms of interacting.
Broughton BK, Lutner N (1995). Chronic
childhood illness: a nursing health promotion
model for rehabilitation in the community. Rehabilitation
Nursing, 20(6), 318-322.
This articles presents a model for culturally
competent nursing that attempts to blend
health education with achievable health
promotion activities, while respecting
cultural differences. It accounts
for the interdisciplinary influence of
care providers, community members, culture,
the family, and the individual.
Campbell JC, Campbell DW (1996). Cultural
competence in the care of abused women. Journal
of Nurse-Midwifery, 41(6), 457-62.
This article discusses the principles
of cultural competence, abuse, and empowerment
as the basis for a model designed for
nurse-midwives who provide clinical intervention
to abused women. The discussion of
cultural competence is based on models
by Campinha-Bacote and Rorie, et al. The
article concludes that nurse-midwives
interact with women at a stage of life
when they are particularly invested in
family and children, and that a culturally
competent assessment of the family unit
enhances the probability of accurate assessment
and effective intervention in care of
abused women.
Campinha-Bacote J, Yahle T, Langenkamp
M (1996 March-April). The challenges
of cultural diversity for nurse educators. Journal
of Continuing Education for Nurses,
27(5), 59-64.
The authors demonstrates how Campinha-Bacote’s
model can provide nurse educators with
a framework for teaching nurses how to
deliver culturally competent care. Cultural
competence is defined as a process, in
which the nurse continuously strives to
achieve the ability to effectively work
within the cultural context of an individual,
family, or community with a diverse cultural
and ethnic background. The authors
make recommendations for cultural diversity
educational programs such as; considering
the culture of the hospital setting prior
to implementation; using teaching from
a culturally competent instructor; being
offered on a voluntary basis; incorporating
creative and non-threatening experiential
exercise (such as cultural bingo, humor
therapy, etc); and providing a positive
learning experience.
Carrillo JE, Green AR, Betancourt JR
(1999). Cross-cultural primary care: A
patient-based approach. Annals
of Internal Medicine, 130(10),
829-835.
This article presents a structure for
a cross-cultural curriculum that assists
physicians in understanding how a patient’s
socio-cultural background affects his
or her health beliefs and behaviors. The
curriculum is grounded in ethnographic
theory as well as medical interviewing
techniques. The curriculum is comprised
of a set of concepts and skills taught
in 5 modules over four 2-hour sessions. Module
1 defines culture and assists participants
in exploring their personal culture and
the “medical culture” and
discusses the attitudes that are fundamental
to cross-cultural encounters. Module
2 explores “core cultural issues”
or situations, interactions, and behaviors
that have potential for cross-cultural
misunderstanding. Module 3 focuses
on patients’ explanatory models
of illness, how the participants can explore
it with individual patients, and how it
effects the physician-patient encounter. Module
4 assists participants in defining and
managing the patient’s social context,
or the social factors that are most relevant
to the medical encounter. The final
module, the capstone of the training,
draws on the skills learned in the previous
modules and teaches participants to facilitate
and negotiate cross-cultural encounters.
Community and Family Health Multicultural
Workgroup, Washington State Department
of Health (1995). Building
cultural competence: A blueprint for action. Prepared
by the National Maternal and Child Health
Resource Center on Cultural Competency.
This report provides specific examples
of effective state strategies in addressing
the needs of diverse growing populations,
as well as challenges that any state would
face in this process. The report
discusses the specific process followed
by the Community and Family Health staff
of the Washington State Department of
Health. It is a blueprint that can
be adapted to suit the specific needs
of agencies. The report emphasizes that
acquiring cultural competence is a process
that requires participation at all levels
of an agency from the individual to the
organizational level. The report
includes references the workgroups found
useful and appendices, which include relevant
definitions, illustrations, guidelines
and forms.
Cultural Competence Strategic Framework
Task Force, New York State Office of Mental
Health (1997). New York state
cultural and linguistic competency standards.
Prepared for the New York State Office
of Mental Health. New York, NY.
This report is the result of a workshop
in which participants worked to develop
performance measures to assess compliance
with cultural competence standards. The
workgroup defined five domains of cultural
competence: accessible inpatient, outpatient,
and community support services; qualified
interpreters; involvement of enrollees
and families role in service development;
culturally and linguistically competent
evaluation, diagnosis, treatment and referral
service; and membership satisfaction.
Cultural Competency Subcommittee for
the Hispanic Agenda for Action, Department
of Health and Human Services (1998). Recommendations
on cultural competency. Prepared
for the Department of Health and Human
Services. Washington, DC.
This article represents the framework
developed by a cultural competence subcommittee
for the HHS 1998 Hispanic Agenda for Action
initiative. The subcommittee cited
the need for an HHS adopted definition
of cultural competence, a coordinated
HHS approach to cultural competence, and
general awareness as reasons for its work. This
article provides an inventory of cultural
competence activities across HHS agencies
that include: policies, mission/principles,
standards, guidelines, performance measures,
cultural competence workgroups and initiatives,
provision of program information in languages
other than English, employment of bilingual
staff, training of staff on culturally
diverse populations, language development
courses, publications on cultural competence,
and funding for cultural competence initiatives.
Davidhizar R, Giger JN (1998). Transcultural
patient assessment: a method of advancing
dental care. The Dental Assistant,
67(6), 34-43.
This article is an analysis of the Davidhizar
and Giger model for cultural competent
care in oral health services. The article
emphasizes that it is essential for persons
who work in a dental office to understand
the differences in individuals from culture
to culture. It is also important to appreciate
that each patient and family is culturally
unique and brings this uniqueness to the
dental office.
DeSantis L (1994). Making anthropology
clinically relevant to nursing care. Journal
of Advanced Nursing, 20(4), 707-715.
This article examines the ability of
transcultural nursing, a field that connects
nursing with anthropology, to operationalize
the concept of culture in order to develop
culturally competent clinicians who are
capable of knowing, using, and appreciating
the effect of culture when providing care
to the individual, group, community, or
family.
Felder E (1990). The nursing cultural
center, a design for cultural diversity.
The ABNF Journal : Official journal
of the Association of Black Nursing Faculty
in Higher Education, Inc, 1(1),
7-9.
The article addresses the rationale for
the development of the Nursing Cultural
Center designed to effectively aid and
train nurses and other health professionals
to meet the challenges of cultural diversity
in health care delivery. The article
includes a cultural nursing center conceptual
model as well as addressing five specific
goals for the center, which have a general
application to institutionalizing cultural
competence in teaching hospitals.
Gonzalez-Calvo J, Gonzalez VM, Lorig
K (1997). Cultural diversity issues
in the development of valid and reliable
measures of health status. Arthritis
Care Research, 10(6), 448-56.
The article discusses the issues of measurement
and assessment in cultural diversity research. The
authors suggest that the development of
instruments for use in culturally diverse
settings and populations involve more
then just translation. Measurements
must be tested for content validity and
appropriate meaning among members of the
targeted group with careful attention
to validity, reliability, and cross-cultural
differences among cultures.
Like RC, Steiner RP, Rebel AS (1996 April).
Recommended core curriculum guidelines
on culturally sensitive and competent
health care. Family Medicine,
28(4), 291-7.
This article outlines a proposed curriculum
for family practice medical residents
and students. The curriculum topics
revolve around attitudes, knowledge, and
skills. The article discusses the
necessity of interspersing the training
throughout a student’s or resident’s
career.
Lister P (1999). A taxonomy for
developing cultural competence. Nurse
Education Today, 19(4), 313-318.
This paper proposes several elements
to develop culturally competent practitioners:
cultural awareness, cultural knowledge,
cultural understanding, and cultural sensitivity. Cultural
awareness is a state in which the student
is able to describe how beliefs, values,
and personal/ political power are shaped
by culture, and that different cultures,
subcultures and ethnicities may validate
different beliefs and values. Cultural
knowledge is a state in which the student
begins to show familiarity with the broad
differences, similarities, and inequalities
in experience, beliefs, values, and practices
among various groupings within society.
Cultural understanding is a state in which
the student recognizes the problems and
issues faced by individuals and groups
when their values, beliefs and practices
are compromised by dominant culture. Cultural
sensitivity is a state in which the student
shows regard of an individual client’s
beliefs, values and practices within a
cultural context, and shows awareness
of how their own cultural background may
be influencing professional practice. Cultural
competence is a state in which the student
provides or facilitates care which respects
the values, beliefs, and practices of
the client, and which addresses the disadvantages
arising from the client’s position
in relation to networks of power. The
authors suggest that the model could possibly
be used to structure a curriculum that
explores the differences among various
social groupings defined according to
gender, generation, lifestyle, or class
as much as ethnicity.
Matherlee K, Burke N (1997 September).
Cross-Cultural Competency in a Managed
Care Environment. National Health Policy
Forum, George Washington University, Issue
Brief No. 705.
This article is a background briefing
on the need for cultural competence. It
outlines the different roles assumed by
the federal government, such as data collection,
service provision, and rules for contracting
organizations, and those assumed by states,
including legislation that addresses cultural
competence, mostly focused on interpreter
requirements. Finally, the article
highlights some innovative programs that
seek to develop cultural competence, including
one to develop a systems approach to assessing
cultural competence in health care organizations. Other
programs highlighted included the following
elements: interpreters, telephone
triage in multiple languages, translated
written materials (e.g., disclosure forms
and patient education), audio-visual presentations
in a range of languages, traditional healing,
diversity training for staff, curricular
guidelines for specialties, annual reviews
of cultural competence, training physicians
on the use of interpreter services, multidisciplinary
outreach teams, and conducting focus groups
to collect data from various ethnic groups.
Meleis AI (1996). Culturally competent
scholarship: Substance and rigor. Advances
in Nursing Science, 19(2), 1-16.
The author addresses the need for cultural
competent scholarship in nursing, as one
aspect of viewing the patient. The authors
warns that “culture is only one
component of what defines a human being;
defining nursing clients as cultural beings
may be as reductionist as defining them
as biological or physiological beings. The
article presents eight proposed criteria
for ensuring rigor and credibility of
culturally competent scholarship that
can be used as guidelines for the research
process and as criteria to evaluate
programming. The eight criteria are:
contextually, communication styles, awareness
of identity, power differentials, disclosure,
reciprocation, empowerment, and time.
Pasick RJ, D’Onofrio CN, Otero-Sabogal
R (1996). Similarities and differences
across cultures: questions to inform a
third generation of health promotion research. Health
Education Quarterly, 23, 142-161.
This article looks at what role culture
should play in health promotion and designing
interventions, specifically presenting
a framework to assess cultural needs of
ethnic groups. The authors identified
the following similar areas of focus in
several different cancer screening programs:
medical care settings, location of community
activities, peer education and testimonials,
message content, frontline professionals
of similar cultural backgrounds to whom
patients could relate to, and style and
language of print material.
Pernell-Arnold A (1998). Multiculturalism:
Myths and miracles. Psychiatric
Rehabilitation Journal, 21(3),
224-229.
The shift of the melting pot paradigm
to multiculturalism is explored. The melting
pot myth relates to the fact that many
groups were not permitted to assimilate.
A foundation is built for the connection
between psychosocial rehabilitation (PSR)
and multicultural approaches. PSR interventions
are to be modified to respond to differences
in cultural belief systems, help-seeking
behaviors, and symptom development. Recommendations
are made on issues and strategies that
PSR programs can utilize when starting
the process of becoming culturally, competent.
Philips D, Leff S, Kaniasty E, Carter
M, Paret M, Conley T, Sharma M (1999). Culture,
race, and ethnicity in performance measurement:
A compendium of resources, version 1. The
Evaluation Center at HSRI and the Center
for Mental Health Services. Prepared for
the Substance Abuse and Mental Health
Services Administration, Depatment of
Health and Human Services. Washington,
DC.
This is an expansive reference on articles
and definitions from multiple government
agencies concerning cultural competence. It
describes an approach to developing and
assessing the cultural competence of the
service system that evolved during the
Evaluation Center at HSRI work with the
NACBHD Outcomes Committee. The compendium
is a compilation of resources and readings
for those interested in the area of providing
or evaluating culturally competent mental
health care.
Puebla-Fortier J, Shaw-Taylor Y
(1999). Cultural and linguistic
competence standards and research agenda
project. Resources for Cross
Cultural Health Care. Prepared for
the Center for the Advancement of Health,
and the Office of Minority Health, Department
of Health and Human Services. Washington,
DC.
This article represents an effort by
the Office of Minority Health at the Department
of Health and Human Services to develop
standards for culturally and linguistically
appropriate services (CLAS). The article
discusses the numerous difficulties in
researching CLAS and its relationship
to outcomes. The fourteen CLAS standards
can be grouped into five categories: culturally
sensitive encounters, choice of providers,
language services, translated materials,
and input into treatment decisions and
service quality. The authors present
research questions that relate the development
of structure, process, and outcome measures
for each of the five categories of standards. They
also suggest possibly linking CLAS-related
indicators to Medicaid risk adjustment,
managed care reimbursement policies, and
utilization related issues as possible
ways to increase demand for CLAS-related
research.
Rubenstein HL, O'Connor BB, Nieman LZ,
Gracely EJ (1991). Introducing students
to the role of folk and popular belief
systems in patient care. Academic
Medicine, 67(9), 566-568.
This article presents the results of
an exercise carried out by the faculty
at The Medical College of Pennsylvania
to improve their medical students’
ability to recognize and work effectively
with the health beliefs and practices
of their patients. The faculty feels
that physicians need to understand the
pervasiveness of the nontraditional beliefs
and practices of their patients and actively
elicit beliefs from their patients in
order to provide the best care possible. The
authors instituted a four-hour session
for sophomore medical students that introduced
guidelines for eliciting and working with
patients’ nonconventional health
beliefs and practices. A pre- and
post-test were administered to test the
students before-and-after knowledge of
(1) the ways in which a physician’s
ignorance of a patient’s health
beliefs and practices can adversely affect
the clinical encounter; (2) the pervasiveness
of nonconventional health beliefs and
practices; and (3) the types of resources
available for learning about these beliefs
and practices. Students’ knowledge
and awareness improved significantly between
the pre- and post-test.
Salimbene S (1999). Cultural competence:
a priority for performance improvement
action. Journal of Nursing
Care Quality, 13(3), 23-35.
This article outlines a model for developing
cultural competence among nurses using
a “cultural filter theory”
of perception whereby every individual
perceives the world around him or her
through a filter that is created and adopted
by all members of a culture. This
filter determines what is said and how
things are said and includes facial expressions,
body language, gestures, behavior, and
speech. The cultural filter is also
responsible for how a person interprets
his or her illness and the cause of illness. The
author outlines the skills and abilities
that constitute culturally competent nursing
care. The stages in this model include: ethnocentricity
or seeing one’s own culture as the
standard measurement, the awareness and
sensitivity to cultural and language differences,
the ability to refrain from forming stereotypes
and judgments that are based on one’s
own cultural framework, the acquisition
of knowledge about the cultures of patients
the organization serves, and the acquisition
of new skills and strategies to identify
cultural differences and to know how to
deal with them in a way that meets patients
needs and the standards of quality care.
Smith LS (1998). Cultural competence
for nurses: canonical correlation of two
culture scales. Journal of
Cultural Diversity, 5(4), 120-126.
This study measures the relationship
among scores and sub-scores on scales
measuring cultural competence among a
population of registered nurses. The
scales used are the Giger and Davidhizar
Transcultural Assessment Model and Theory,
the Cultural Self-Efficacy Scale (CSES),
Cultural Attitude Scale (CAS –Modified),
in addition to a knowledge base questionnaire.
Texas Department of Health. (1997)
Pursuing organizational and individual
cultural competency: An epistemology of
the journey towards cultural competency.
Prepared for the Maternal and Child Health
Bureau, Health Resources Services Administration,
U.S. Department of Health and Human Services.
This article explores the limits, validity,
grounds, principles and standards for
cultural competence. The publication
explores the distinction between cultural
diversity and cultural competence, as
well as the myths and misconceptions related
to cultural differences, which are given
credence and validity. For example
the authors point out the weakness of
training curriculums that teach diversity
as recognition of differences. A
manual provides tools for defining training
objectives, assessing the training environment
and assessment of training methods and
outcomes. The authors argue that
from individual expansion comes organizational
impact, which can only be measured with
proper training standards and means of
evaluating the impact.
Weiss CI, Minsky S (1994). Program
self-assessment survey for cultural competence:
manual. Prepared for the New
Jersey Division of Mental Health and Hospitals.
This survey was developed by the Multicultural
Services Advisory Committee to assist
mental health programs in delivering culturally
competent care. The survey is not aimed
at assessing staff’s level of cultural
competency, but rather an organization’s
ability to address the needs of culturally
diverse groups. The survey assesses
an organization’s level of cultural
competency by reviewing program policies
and practices. Survey questions address
organizational practices related to client
diagnosis and assessment, physical characteristics
of the facility, staff recruitment, and
client participation. The scores are tallied
to create a program profile.
Woloshin S, Bickell NA, Schwartz LM,
Gany F, Welch HG (1995). Language
barriers in medicine in the United States. JAMA,
273(9), 724-728.
This article reviews the current status
of interpreter services in the United
States health care system, the clinical
impact of inadequate interpretation and
the legislative responses to the language
needs of patients with limited English
proficiency. Patients and clinicians
tend to rely on one of three sub-optimal
mechanisms for interpretations: (1) their
own language skills, (2) the skills of
family or friends, or (3) ad hoc interpreters.
The DHHS Office for Civil Rights views
inadequate interpretation as a form of
discrimination. Language barriers
impair the exchange of information from
patient to physician in several ways leading
to misdiagnosis and non-education. Inadequate
interpretation also raises ethical problems
related to informed consent. The authors
offer a number of simple low cost interventions
to improve access to bilingual services
including: (1) multilingual signs and
videos to inform patients about interpreter
services; (2) bilingual phrase sheets
for staff and patients; and (3) telephone
interpreter access.
Performance Measures and/ or Indicators
Abt Associates (2000). Report
on recommendations for measures of cultural
competence for the quality improvement
system for managed care. Prepared
for the Health Care and Financing Administration.
Washington, DC.
This report includes a set of recommendations
for measures of cultural competence of
managed care organizations that provide
care to Medicare and Medicaid beneficiaries
under contracts with HCFA or with State
Medicaid agencies. The measures were developed
for use in the Quality Improvement System
for Managed Care (QISMC), which is a system
designed to ensure that organizations
providing health care services under contract
protect and improve the health and satisfaction
of enrolled beneficiaries. Recommendations
for measures were developed from input
from experts in the field of cultural
competence. The Expert Panel recommended
that HCFA develop measures of the following
three types: 1) disparity-based measures;
2) enrollee-based measures; and 3) standards-based
inventories of current practices. Disparity-based
measures would identify disparities in
access to care and disparity in preventive
care, such as flu shots. Enrollee-based
measures would assess the beneficiaries’
ability to choose congruent providers
and language services. Standard-based
measures would assess whether MCO had
a process for identifying and addressing
disparities.
The Bureau of Primary Health Care. (1999).
Cultural Competence: A Journey.
Health Resources and Services Administration,
Bureau of Primary Health Care.
This publication summarizes the experiences
of community programs affiliated with
the Health Resources and Services Administration’s
Bureau of Primary Health Care that provide
services to culturally diverse populations.
This document profiles a variety of programs
such as the Sunset Park Family Health
Center in New York and the Red Tail Training
and Health Center in Minneapolis and chronicles
their experiences in providing culturally
competent service delivery, such as incorporating
traditional healing, creating health facilities
that are more welcoming and attractive
to patients through signage and interpreters,
and training culturally sensitive clinicians.
The document also outlines 5 essential
elements that contribute to a system’s
ability to become more culturally competent,
7 domains of cultural competence and describes
public health studies that demonstrate
improved health outcomes resulting from
providers’ ability to bridge cultural
gaps between themselves and their patients.
Center for Mental Health Services (1998).
Cultural competence standards
in managed mental health care: Four
underserved/underrepresented racial/ethnic
groups. Prepared for the Substance
Abuse and Mental Health Services Administration,
Department of Health and Human Services.
Purchase Order No. 97M047622401D.
This report addresses the need to ensure
the provision of culturally competent
services to underserved and underrepresented
racial/ethnic groups in managed care settings.
The report provides tools to guide the
provision of culturally competent mental
health services to four racial/ethnic
populations: Hispanics, American Indians/Alaska
Natives, African Americans and Asian/Pacific
Islanders. Input was gathered from expert
panels of consumers, mental health services
providers and academic clinicians representing
each of the four racial/ethnic populations.
Each panel reviewed mental health research
and services literature that focused on
their respective population and developed
a consensus around how best to achieve
culturally competent managed behavioral
health care for its target population.
Two types of standards were developed:
overall system guidelines, and clinical
standards and implementation guidelines.
Overall system guidelines focused on ensuring
a culturally competent system of care
and included standards on cultural competence
planning, governance, benefit design,
outreach, quality improvement, information
systems, and human resource development. Clinical
standards and implementation guidelines
focused on ensuring culturally competence
clinical practices and included: discharge
planning, treatment services, and communication
styles. For each standard, the report
included a list of recommended performance
indicators and outcomes.
Flores G (1999). A model of cultural
competency in health care. Progress
Notes: A Newsletter of the Massachusetts
Chronic Disease Improvement Network. The
Massachusetts Chronic Disease Improvement
Network, 3(1), 1-3.
This article includes a model of cultural
competency and tools for use by providers
to become knowledgeable about the role
of culture in the patient-provider interaction. The
model includes 5 components; (1) “normative
cultural values”, which focuses
on a clinician becoming familiarized with
the values within a patient’s culture;
(2) “language issues”, which
focuses on the use of interpreter services
and promotion of bilingual skills among
clinicians; (3) “folk illnesses
and remedies”, which outlines a
four step method for acquiring information
from patients on their traditional treatment
practices; (4) “patient/parent beliefs”,
which instructs clinicians on identifying
beliefs that impact care and approaches
for communicating to patients alternatives
to traditional practices; (5) “provider
practices”, which focuses on tracking
ethnically based disparities in screening,
prescriptions and health outcomes.
Goode TD (1989. Revised 1993, 1996, 1999
and 2000) Promoting cultural and
linguistic competency. self-assessment
checklist for personnel providing services
and support to children with special health
needs and their families. Georgetown
University Child Development Center- National
Center for Cultural Competence (NCCC). Washington,
DC.
This publication includes self-assessment
tools developed by Georgetown University
Child Development Center’s National
Center for Cultural Competence to be used
by personnel providing primary health
care services. Self-assessment tools were
developed for a variety of topic areas,
including “values and attitudes”,
“communication styles”, and
the “physical environment.”
Personnel are provided with a checklist
that assesses how well they are demonstrating
or engaging in practices that promote
culturally diverse and competent services.
Cohen E, Goode TD (1999). Policy
Brief 1: Rationale for cultural competence
in health care. Georgetown University
Child Development Center- National Center
for Cultural Competence (NCCC). Washington,
DC.
Goode TD, Sockalingam S, Brown M &
Jones W (2000). Policy Brief 2:
Linguistic competence in primary health
care delivery systems: implications for
policy makers. Georgetown University
Child Development Center- National Center
for Cultural Competence (NCCC). Washington,
DC.
These policy briefs are produced by Georgetown
University Child Development Center’s
National Center for Cultural Competence.
Policy Brief 1 and 2 include a checklist
for organizations to assess how well they
facilitate the development of culturally
and linguistically competent primary health
care policies and structures. This checklist
includes items related to the incorporation
of cultural competence principles into
mission statements and policies regarding
staff training, professional development
and evaluation, and the allocation of
dedicated resources to cultural competence
activities.
Health Resources and Services Administration
(2000). Cultural Competence Works.
Awards of Excellence. “Certificates
of Recognition Nominated Programs of Note”
and “Certificate of Recognition.”
U.S. Department of Health and Human Services.
Washington, DC.
This booklet includes an abstract of
the “Cultural Competence Works Awards
of Excellence” presented to various
health care programs. One abstract included
a description of the SouthCove Community
Health Center in Boston, Massachusetts
(SCCHC). The abstract outlined activities
conducted by the Center to ensure cultural
competence, including performing client
assessment and care planning in the client’s
primary language, recruitment of a bilingual
staff, provision of interpreter training
for medical staff, and the delivery of
intensive, bilingual/bicultural outreach
and community health education. Other
programs profiled included the South Park
Family Health Center Network, which conducts
yearly community needs assessment, provides
new staff orientation training in cultural
diversity, uses Americorp members to delivery
outreach and educational activities, and
has a Cultural Access Task Force focused
on developing and implementing culturally
competent policies. The awards were presented
by the Office of Minority Health, Maternal
and Child Health Bureau, and Center for
Managed Care at a January 10, 2000 ceremony.
Lavizzo-Mourey R, Mackenzie ER (1996).
Cultural competence: essential measurements
of quality for managed care organizations.
Annals of Internal Medicine,
124, 919-921.
This article addresses the need to establish
guidelines of cultural competence for
managed care organizations. In this article,
cultural competence is defined as the
demonstrated awareness and integration
of the following three components: (1)
“health-related beliefs and cultural
values”, which incorporates the
belief system and perspectives of cultural
subpopulations; (2) “disease incidence
and prevalence”, which requires
that MCOs take into account the varying
disease incidence among racial and ethnic
subpopulations and collect accurate epidemiologic
data to guide decisions about health education,
screening and treatment programs; and
(3) “treatment efficacy”,
which focuses on the population-specific
pharmacologic efficacy of treatment across
different populations. The article provides
various illustrations of these three components
in managed care organizations.
Mason JL (1995). Cultural competence
self-assessment questionnaire: A manual
for users. Portland State University,
Research and Training Center on Family
Support and Children’s Mental Health. Washington
State.
This report includes an instrument to
access cultural competence in agencies
serving children and families. The instrument
includes a version for service providers
and for administrative personnel. Questions
included in the instrument provide ways
to evaluate understanding and application
of cultural competence concepts by staff.
This tool is applicable across a wide
range of settings.
Maternal and Child Health Bureau (2000).
Maternal and child health services
Title V block grant program: guidance
and forms for the Title V application/annual
report. U.S. Department of Health
and Human Services. Washington, DC.
This document contains instructions for
Title V Maternal and Child Health Block
Grant grantees for submitting application
and annual reports. Contained within this
document are performance measures on which
grantees are required to report. Specific
measures related to cultural competence
include health outcome measures and developmental
health status indicator measures.
Maternal and Child Health Bureau (1990).
State children with special health care
needs Title V directory workshop: Improving
state services for culturally diverse
populations. Prepared for Division of
Services for Children with Special Healthcare
Needs, Maternal and Child Health Bureau,
Health Resources and Service Administration,
and Department of Health and Human Services.
Washington, DC.
This report summarizes proceedings from
a Work Group convened during a May, 1990
conference entitled “Cultural Perspectives
in Service Delivery for Children and Families
with Special Needs.” The conference
was convened by the Maternal and Child
Health Bureau to assist states in assessing
and improving delivery of services to
culturally diverse populations of children
with special needs and their families.
The Work Group developed specific guidelines,
strategies, policies and activities that
could be undertaken by states to accomplish
the goal of culturally competent health
care delivery. The Work Group identified
critical components of culturally competent
programs and outlined a set of objectives
to assist States in achieving these components.
Munoz RH, Sanchez AM. Developing
culturally competent systems of care for
state mental health services. Prepared
for Center for Mental Health Services,
Substance Abuse and Mental Health
Services Administration, Department of
Health and Human Services. Washington,
DC.
This report examines the impact of culture
on mental health, strategies for instituting
cultural competency into mental health
care, and a plan of action for developing
a culturally competent system of care.
The report provides a framework of a culturally
competent system of care and outlines
essential components of that system. Also
included is the experience of five states
that apply culturally competent principles
in real-life settings. States recount
challenges and difficulties in implementing
these principles. This report also includes
an appendix of assessment tools. Those
tools include patient satisfaction surveys,
and provider and organization self-assessment
of cultural competency.
Nelkin VS (1994). Implementing
the surgeon general’s action agenda:
To improve access to care and quality
of life for all children with special
healthcare needs and their families. Prepared
for Division of Services for Children
with Special Health Care Needs, Maternal
and Child Health Bureau, Health Resources
and Service Administration, and Department
of Health and Human Services. Washington,
DC.
This report describes results of a survey
conducted in 1992-1993 of Special Projects
of Regional and National Significance
(SPRANS) and Maternal and Child Health
Improvement Project (MCHIP) grantees.
The survey assessed grantees’ progress
in achieving action steps outlined by
the Surgeon General. One of these action
steps related to culturally competent
care. Assessment of progress was measured
along a scale ranging from “no action
taken” to “activity has become
standard practice in other settings.”
In terms of culturally competent care,
grantees were assessed on whether they
implemented culturally competent care
concepts and activities, such as translated
materials, incorporation of cultural values
in services delivery and planning, inclusion
of culturally diverse families on advisory
groups, recruitment and hiring of culturally
diverse staff, and training of staff on
cultural competence principles. Specific
indicators for each of these activities
were also identified.
New York State Office of Mental Health.
The Research Foundation for Mental Hygiene.
(1998). Cultural competence performance
measures for managed behavioral healthcare
programs. In Collaboration with
the Center for the Study of Issues in
Public Mental Health. Prepared for the
Substance Abuse and Mental Health Services
Administration, Center for Mental Health
Services, Department of Health and Human
Services. Washington, DC.
This report was undertaken to address
whether services delivered by mental health
organizations reflected and responded
to the needs of culturally and ethnically
diverse populations. Input from a steering
committee, an expert panel, and focus
groups was used to develop a conceptual
framework of cultural competence and a
set of performance measures aimed at assessing
how well managed care organizations and
other mental health programs are providing
services to multicultural groups. The
conceptual framework of cultural competence
was developed using 6 domains of mental
health service delivery: 1) needs assessment;
2) information exchange; 3) services;
4) human resources; 5) plan and policies;
and 6) outcomes. Performance measures
were selected for each of these domains
based on: a review of standards of cultural
competence developed by Federal and State
entities and managed care organizations;
a review of literature focused on mental
health systems and cultural competence;
and interviews with experts in the field
of cultural competence and consumers and
providers of mental health care services.
Performance measures were applied to three
levels: 1) administrative level; 2) provider
network level; 3) and the individual provider
level and data sources were identified.
The report concludes with a set of recommendations
for selecting the most appropriate performance
measures and a plan for implementing these
measures within the internal policies
and planning of an organization.
Office of Minority Health (1999). Assuring
cultural competence in health care: Recommendations
for national standards and outcomes-focused
research agenda. Recommended
Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health
Care Services. Prepared for the U.S. Department
of Health and Human Services. Washington,
DC.
This report responds to the need to develop
consensus and standards regarding what
constitutes cultural or linguistic competence
in health care service delivery. This
report outlines a set of 14 standards
for use by various stakeholders, including
providers, policymakers, accreditation
and credentialing agencies, purchasers,
patients, advocates, educators and the
health care community in general. The
expectation is that the standards will
provide guidance to providers on how to
provide culturally competent care and
provide policymakers and consumers with
the tools to evaluate and assess whether
a provider is delivering culturally competent
care. The recommended standards were developed
with input from a national advisory committee
of policymakers, health care providers,
and researchers. The process used in developing
the standards included the formulation
of research questions and a review of
technical and policy literature to identify
categories of cultural competence. A content
analysis of the literature was conducted
which identified two thematic clusters
corresponding to (1) linguistic competence
(i.e., language access, interpreter and
translation services) and (2) cultural
competence (i.e., patient, staff and organizational
cultural diversity management). An initial
list of 21 draft standards was consolidated
to 14 standards. The standards relate
to a variety of areas, including policies
and organizational structures, consumer
involvement, training and education of
staff, and the provision of interpretation
services. Along with recommended national
standards, the report also outlines a
research agenda for relating the standards
to outcomes.
Texas Department of Health. Journey
towards cultural competency: Lessons learned. National
Maternal and Child Health Resource Center
on Cultural Competency. Prepared for the
Maternal and Child Health Bureau, Health
Resources and Services Administration,
U.S. Department of Health and Human Services.
Washington, DC.
This report outlines a process for achieving
cultural competency and describes lessons
learned from this process. The National
Resource Center on Cultural Competence
outlined 10 steps for achieving cultural
competency: 1) gathering demographic information
on clients and information from staff
on knowledge, attitudes, and skills related
to cultural competence; 2) achieving top
management support to implement cultural
competence; 3) establishing a work group/task
force to place a plan into action; 4)
conducting an organizational assessment
to indicate capacity and need; 5) developing
a long range plan based on the assessment
evaluation; 6) conducting of cultural
competency training of staff and providers;
7) coordinating with collaborators in
the public and private sector; 8) implementing
long range plans at the individual, policy,
administrative, and service provision
levels; 9) using consultants to assist
in cultural competency assessment; and
10) disseminating information and experiences
to stakeholders.
Tirado M (1996). Tools for monitoring
cultural competence in health care.
Prepared by the Latino Coalition for a
Health California. San Francisco, CA.
This report was prepared for the Office
of Planning and Evaluation at the Health
Resources and Services Administration.
The report includes tools to monitor providers’
cultural competence. Expert panels comprised
of primary care physicians and other health
care professionals were convened to assist
in the development of these provider cultural
competence tools. The Expert Panel focused
on developing tools targeted at three
chronic conditions: asthma, diabetes,
and hypertension. Other input was gathered
from individual panel member interviews
and focus groups conducted with patients.
A provider self-assessment and a patient
satisfaction survey was developed and
included indicators of cultural competence
in managed care and other settings.
Program- and Condition-Specific
Studies
General and Consumer Satisfaction
Baker DW, Parker RM, Williams MV, Coates
WC, Pitkin K. (1996). Use and effectiveness
of interpreters in an emergency department. JAMA,
275(10), 783-788.
This article assesses the use of interpreters
in the emergency departments, examining
when their use is appropriate and what
impact their use has on consumers’
understanding of their diagnosis and treatment,
and their satisfaction with care. Variables
examined included interpreter use, necessity
of interpreter, providers’ ability
to speak Spanish, and consumers’
ability to speak English. One issue
that the authors raise is the high prevalence
of illiteracy in limited English proficient
patients and the need to consider this
when deciding whether or not to employ
an interpreter. Interpreter use varied
by both patients’ and examiners’
self-reported language proficiency and
decreases in language proficiency corresponded
with increases in interpreter use. Patients’
understanding of discharge directions
and diagnosis was less when interpreters
were not used.
Barton JA, Brown NJ (1992). Evaluation
study of a transcultural discovery learning
model. Public Health Nursing,
9(4), 234-241.
This qualitative, descriptive study explores
the extent to which student’s discovery
learning, centered around cultural understanding
and sensitivity occurs in clinic rotations. The
study specifically looked at 13 students
working with migrant health communities. The
findings confirmed that students who participated
built a deepening respect for a cultural
minority group, honed skills to identify
differences in cultural norms, and recognized
the rewards gained in their transcultural
experience.
Blackhall LJ, Murphy S, Frank G, Michel
V, Azen S (1995). Ethnicity
and attitudes toward patient autonomy. JAMA,
274(10), 820-825.
This article summarizes a study that
examines the differences in the attitudes
of elderly subjects from different ethnic
groups toward disclosure of the diagnosis
and prognosis of a terminal illness and
toward end-of-life decision-making. The
study examines the principle of patient
autonomy that asserts that the patients
have certain rights to make decisions
about their medical care. The study
used the Ethnicity and Attitudes Toward
Advanced Care Directives Questionnaire
and interviewed 200 individuals. The
study showed that Korean- and African-Americans
were significantly less likely that European-
and Mexican-Americans to believe that
a patient should be told the diagnosis
of metastatic cancer or a terminal prognosis
and less likely to believe that patients
should make decisions about the use of
life-support technology. Mexican-
and Korean-Americans instead rely on their
families to make these decisions. The
authors discuss a “family-centered”
model whereby it is the sole responsibility
of the family to hear bad news about the
patient’s prognosis and diagnosis
and make difficult decisions regarding
life-support.
Braithwaite RL, Lythcott N (1989). Community
empowerment as a strategy for health promotion
for black and other minority populations.
JAMA, 261(2), 282-283.
This article highlights the need for
community empowerment and cultural competence
in improving health outcomes for minority
communities. The authors define community
empowerment as a process of increased
control by groups over consequences that
are important to their members. They
state that focused prevention efforts
should emerge from a knowledge of and
respect for the culture of the target
community.
Cooper-Patrick L, Gallo JJ, Gonzales
JJ, Vu Hong TP, Neil R., Nelson CF, Daniel
E (1999). Race, gender, and partnership
in the patient-physician relationship. JAMA,
282(6), 583.
The researchers conducted a telephone
survey of 1816 adults age 18 to 65 with
the objective of describing how the race
and ethnicity, and the gender of patients
and physicians are associated with physicians’
participatory decision making styles. The
data suggested that African Americans
rate their visits with physicians as less
participatory than whites thus demonstrating
a need for improved cross cultural communication.
Dana RH (1998). Projective assessment
of Latinos in the United States: current
realities, problems and prospects. Cultural
Diversity and Mental Health,
4(3), 165-184.
This article examines biases in assessment
and professional mental health practice
with Latino populations and suggests a
measure for assessment, followed by several
descriptive tests and suggestions for
reduction of cultural based bias through
guidelines. The author critiques
the major projective methods used by psychologist
with Latino populations and suggests guidelines
for nine major areas to promote competent
assessment practice with Latinos. The
nine areas are: population diversity,
language, service delivery style, acculturation,
interpretation, psycho-diagnosis, personality
theory, and shared personality findings.
Delgado JL, Johnson CL, Roy I, Trevino
FM (1990). Hispanic health and nutrition
survey: methodological considerations. American
Journal of Public Health, 80
Suppl, 6-10.
This article focuses on the methodological
considerations of HHANES (Hispanic Health
and Nutrition Education Survey) and the
difficulties of assessing particular topics
related to ethnicity, such as acculturation. HHANES
studied chronic conditions and some behavioral
issues, including nutrition. HHANES
uses five data collection techniques: direct
physical exams, diagnostic testing, anthropometry,
lab analysis, and interview. Virtually
all interview staff were bilingual and
bicultural.
Denboba DL, Bragdon JL, Goldman T (1998).
Reducing health disparities through cultural
competency. Journal of Health
Education, 29(5), S47.
This article focuses on how HRSA has
defined and integrated cultural competence
in the programs it funds and provides
an overview of HRSA’s programs in
cultural competence, and lessons learned
from the HRSA programs. The article
identifies potential resources or partners
in the delivery of culturally competent
health care within HRSA programs. Additionally,
it suggests strategies in operationalize
culturally competent policies and practices
through lessons learned by other’s
experiences. The article suggests
that HRSA’s role in the area of
cultural competence has been and will
continue to be providing leadership, guidance,
and opportunities for collaborating in
training, development of community and
consumer partnerships, developing model
strategies, and research.
Dressler SW, Viteri FE, Chavez A, Grell
GA, Dos Santos JE (1991). Comparative
research in social epidemiology: measurement
issues. Ethnicity and Disease,
1(4), 379-393.
This article summarizes a complex epidemiological
methodology that derives and evaluates
cross-culturally valid measures of behavioral
and sociocultural factors that may lead
to an increase in blood pressure or the
risk of disease. The author suggests
that not all variance in blood pressure
can be explained by the traditional risk
factors for hypertension (i.e. diet, heredity,
exercise, etc.). Instead social and
cultural factors also have an impact. It
is, however, difficult to measure these
social and cultural factors in a way that
is comparable across cultures. The
purpose of this study is to develop a
set of variables that measure the effects
of social and cultural factors on blood
pressure that are equivalent across cultures
(measurement equivalence).
Eisenberg DM, Kessler RC, Foster C, Norlock
FE, Calkins DR, Delbanco TL (1993). Unconventional
medicine in the United States: prevalence,
costs, and patterns of use. New
England Journal of Medicine,
328(4), 246-252.
This paper presents the results of a
study undertaken to estimate the prevalence,
use, cost, and reasons for use of “unconventional
medicine” in the United States,and
providers’ awareness of it. Unconventional
therapies are defined as medical interventions
not widely taught at U.S. medical schools
or generally available at U.S. hospitals. A
representative sample of 1539 households
was contacted and interviewed using a
phone survey. The results from these
interviews were extrapolated to the U.S.
population. The results showed that
one in three respondents used at least
one unconventional therapy in 1990 and
that relaxation techniques, chiropractic,
and massage were the therapies used most
often. Almost 9 out of 10 respondents
saw an unconventional provider without
the recommendation of their medical provider
and most respondents paid the entire cost
of their visit out of pocket.
Gant LM (1996). Are culturally sophisticated
agencies better workplaces for social
work staff and administrators? Social
Work, 41(2), 163-71.
This article examines staff perceptions
of an agency as a culturally sophisticated
organization that promotes policies and
practices that are either barriers to
or facilitators of appropriate services
for culturally diverse clients. Cultural
sophistication is used by the author to
outline three themes: knowledge and information
about cultures, how people feel about
cultures, and how to effectively interact
with staff and clients of other cultures.
Health Resources Services Administration
(1999). HRSA fact sheet:
Assuring access to health care.
Department of Health and Human Services.
Washington, DC.
This article describes HRSA efforts to
assure access to health care, specifically
discussing access in underserved communities,
access for populations with HIV/AIDS,
access for women and children, access
to better trained professionals, and access
to quality and equality of care. HRSA’s
programs to improve access to better trained
professionals targets increasing diversity,
including racial and ethnic diversity,
in the workforce by providing training
opportunities and support.
Hennessy LL, Friesen MA. (1994). Perceptions
of quality of care in a minority population:
A pilot study. Journal of Nursing
Care Quality, 8(2), 32-37.
This paper presents the results of a
study done to assess Mexican-American
patients’ perceptions of quality
of care delivered by health care providers
in two hospitals. This study used
the “Patient Judgment System”
to assess patients’ perception. Results
showed that Mexican-Americans were more
concerned with the environment and “caring”
with which care was delivered rather than
the technical or skill levels of care
provided. In addition, it was evident
that those subjects in the lower socioeconomic
groups were generally less satisfied with
the care they received.
Kington RS, Smith JP (1997). Socioeconomic
status and racial and ethnic differences
in function status associated with chronic
disease. American Journal
of Public Health, 87(5), 805-810.
This article discusses the relationship
between socioeconomic status and racial
and ethnic differences in the prevalence
of diabetes, heart conditions, hypertension,
and arthritis. The study shows that
socioeconomic status plays a greater role
in explaining racial and ethnic differences
in an individuals’ ability to function
once someone is ill, rather than explaining
the differences in the probability of
becoming ill.
Ludwig-Beymer P, Blankemeire JR, Casas-Byots
C, Suarez-Balcazar Y (1996). Community
Assessment in a Suburban Hispanic Community:
A Description of Method. Journal
of Human Lactation, 12(2), 117-122.
This article addresses the methods used
to learn about the Hispanic community
in Des Plaines, Illinois. The researchers
based their methods on Leininger’s
theory of culturally competent care. Steps
included conducting three focus groups,
constructing a structured interview guide,
collecting data, analyzing data and then
reporting the findings back to the Hispanic
community. As a result of the analysis
the Genesis Health and Empowerment Program
was developed.
Massachusetts Chronic Disease Improvement
Network (1999). Progress
notes: A newsletter of the Massachusetts
chronic disease improvement network. 3(3).
The newsletter contains two articles. One
looks at practicing culturally sensitive
health care through the example of using
folk remedies in conjunction with biomedical
remedies. The article focuses on
the importance of gathering a full patient
history suggesting that if the doctor
only gathers the information needed for
a biomedical diagnosis and treatment plan,
they will miss the nuances of the patient’s
story. This can lead to an unsuccessful
encounter. The second article suggests
a model for ascertaining the cultural
attributes of each patient, and responding
appropriately to the cultural values,
language issues, folk remedies, patient
beliefs, and ethnic disparities in health
and use of services.
Moy E, Bartman BA (1996). Physician
race and care of medically indigent patients.
JAMA, 273(19), 1515-1520.
This article presents the results of
a study that uses the 1987 National Medical
Expenditure Survey to examine the relationship
between physician’s race and care
provided to racial minority patients and
medically indigent patients. The
purpose of the study was to see if nonwhite
physicians are more likely to provide
care to racial and ethnic minorities,
the medically indigent, and sicker patients. The
results revealed that minority patients
were more than four times more likely
to receive care from nonwhite physicians,
than non-Hispanic white patients. Low-income,
Medicaid, and uninsured patients were
also more likely to receive care from
nonwhite physicians. Individuals
who receive care from nonwhite physicians
were more likely to report worse health. The
authors raise several concerns with these
results including that nonwhite physicians
may be financially penalized for caring
for nonwhite populations and the need
for enhanced instruction in multicultural
diversity among physicians.
Perry CM, Shams M, DeLeon CC (1998). Voices
from an Afghan community. Journal
of Cultural Diversity, 5(4),
127-131.
This article applies two specific assessment
tools to examine an Afghan community in
northern California. The article
suggests that a major role of the community
health nurse should be advocating to ensure
that the need of specific ethnic and racial
communities are met. The article
presents an example of how this assessment
can be conducted.
Starfield B, Cassady C, Nanda J, Forrest
CB, Berk R (1998). Consumer experiences
and provider perceptions of the quality
of primary care: implications for managed
care. Journal of Family Practice,
46(3), 216-226.
This article summarizes a study focused
on determining the extent to which consumer
and provider reports of primary care differ
according to particular characteristics
of the primary care setting. A telephone
survey was administered to a random sample
of Washington, DC residents to determine
their experiences with care provided to
one of their children. The primary
care physician of the respondent was also
sent a survey. The results showed
that both consumers and their providers
in settings characterized by high degrees
of limitation of physician autonomy or
by capitation reported better first-contact
and a greater range of services available
that did consumers with low degrees of
limitation. Consumers also reported
better family-centeredness in these settings.
Todd KH, Samaroo N, Hoffman JR (1993). Ethnicity
as a risk factor for inadequate emergency
department analgesia. JAMA, 269(12),
1537-1539.
This article summarizes the results of
a study that determined whether Hispanic
patients with fractures to the humerus,
radius, ulna, femoral shaft, tibia, and
fibula were less likely to receive emergency
department (ED) analgesics (pain relief)
than similar non-Hispanic white patients. The
study looked at the UCLA Emergency Medicine
Center ED records for a 2-year period
and used all Hispanic and non-Hispanic
white patients between 15 and 55 years
of age. The study group consisted
of approximately 139 patients –
31 were Hispanic and 108 non-Hispanic. Results
showed that non-Hispanic whites were twice
as likely to receive ED pain medication
and Hispanics were more likely to receive
low-dose, oral or nonnarcotic analgesics. After
controlling for several variables including
ethnicity, sex, language, and insurance
status, Hispanic ethnicity was still the
strongest predictor of no analgesic. The
authors suggest several reasons for this
difference including the presence
of patient advocates who might influence
physicians and the failure on the
part of physicians to recognize pain in
culturally different patients.
Warda MR (2000). Mexican Americans’
perception of culturally competent care. Western
Journal of Nursing Residence, 22(2),
203-24.
The purpose of this study was to identify
the culturally competent concepts from
the perspective of the Mexican American
health services consumer. The researchers
conducted focus group interviews with
Mexican American registered nurses and
Mexican American lay recipients regarding
the indicators of culturally competent
care. The authors suggest that respect,
caring, understanding, and patience in
health care encounters are the core of
culturally competent care.
Wright F, Cohen S, Caroselli C (1997). Diverse
decisions: how culture affects ethical
decision making. Critical
Care Nursing Clinic of North America, 9(1),
63-74
This article looks at the concerns faced
by the critical care nurse, often the
first one to identify an ethical concern,
in assisting patients and families in
making ethical health care decisions,
specifically addressing end of life issues. The
authors present a process through which
the critical care nurse can address how
to assists the patient and family in ethical
decision making. The article addresses
the behavioral manifestations of culture
that influence the patient such as verbal
communication, non verbal communication,
space, family structure, time, and view
of illness and health. Finally the
authors briefly address the specific cultural
considerations for African Americans,
Latinos, Filipinos, Southeast Asians,
Native Americans and Jewish Americans.
Various (1991). Hispanic health
issue. JAMA, 265(2),
238-241.
This articles highlights some of the
key issues in access to care for Hispanic
populations, including disparities in
health status and location and institutional
factors such as farm work, air/water quality
concerns in border communities, and the
paucity of Hispanic health professionals.
Cancer
Burns R, McCarthy E., Freund K, Marwill
S, Shwartz M, Ash A, Moskowitz M
(1996). Black women receive less
mammography even with similar use of primary
care. Annals of Internal
Medicine, 125(3), 173-182.
Using Medicare claims from ten states,
this article examines differences in mammography
use between elderly black and white women. The
use of mammography seems to increase as
primary care visits increase, but black
women had lower use rates than white women
across all levels of primary care. However,
within race, mammography use by black
women did not vary greatly. Research
has demonstrated that physicians are more
likely to encourage elderly white women
to obtain mammograms than elderly black
women, highlighting concerns around provider
attitudes. Black women have also
been shown to have less knowledgeable
about mammography than white women, highlighting
concerns about patient education.
Davis DT, Bustamante A, Brown CP, Wolde-Tsadik
G, Savage EW, Cheng X, Howland L (1994). The
urban church and cancer control: a source
of social influence in minority communities. Public
Health Reports, 109(4), 505-506.
This article examines how to create the
conditions for church-based cancer control,
citing securing pastoral commitment and
selecting lay health leaders as two critical
components in its demonstration. The
demonstration targeted African-American
and Latina women and involved 24 churches
in Los Angeles that offered cervical cancer
education and Pap Smears to women 21 years
and older. By the end of the two year
project, 52 percent of the churches initiated
continuation cancer control activities. “Social
influence models that use indigenous sources
of social support can exert a positive
influence on the participation of minority
women in cancer control.”
Mohrmann CC, Coleman EA, Coon SK, Lord
JE, Heard JK, Cantrell MJ, Burks EC (2000). An
analysis of printed breast cancer information
for African American women. Journal
of Cancer Education, 15(1), 23-27.
The Delta project was designed to increase
breast cancer screening among minority
women by educating health care professionals,
who serve these populations, about breast
health. The research team did a review
for appropriate educational materials,
found none, and discussed the importance
of recognizing that the culture of the
patient influences the effectiveness of
printed materials motivating compliance
and changing attitudes and behaviors.
Perez-Stable E, Sabogal F, Otero-Sabogal
R, Hiatt R, Mcphe S (1992). Misconceptions
about cancer among Latinos and Anglos. JAMA,
268(22), 3219-3223.
This article summarizes findings of a
survey comparing knowledge about and attitudes
toward cancer among self-identified Latino
or Anglo health plan members. The
study showed that after adjusting for
education, age, sex, county of residence,
health status and employment, Latinos
remained significantly more likely to
have misconceptions about the causes of
cancer and to have less knowledge about
the symptoms of cancer. In addition,
the study suggests that attitudes that
may be detrimental to cancer control efforts
were more prevalent in the Latino population. The
fear of cancer as a “death sentence”
and the perception that there is little
a person can do to prevent cancer are
themes found in the Latino population. The
authors point out that the cultural concept
of fatalismo (or fatalism) may lead some
Latinos to assume that there is little
a person can do to alter his or her fate
in developing cancer, and thus may lead
some to be less likely to change behavior
that increases cancer risk. The authors
suggest that new materials need to be
developed in simple Spanish to provide
accurate cancer information and address
ethnic-specific issues and concerns.
White JE, Begg L, Fishman NW, Guthrie
B, Fagan JK (1993). Increasing
cervical cancer screening among minority
elderly: education and on-site services
to increase screening. Journal
of Gerontological Nursing, 19(5),
28-34.
This articles summarizes findings of
a study designed to determine the degree
to which an intensive nursing intervention,
consisting of education and onsite cervical
cancer screening, could increase the rate
of cervical cancer screening in elderly
women. The authors point out that
race is a predictor of the stage at which
cervical cancer is diagnosed as elderly
black and Hispanic women have lower rates
of cervical cancer screening. The
study found that educational interventions
increase the awareness of the need for
routine Pap testing among the elderly
but leaves unanswered questions about
the most effective and efficient approaches
to such interventions.
Yancey AK, Waldlen L (1994). Stimulating
cancer screening among Latinas and African
American women. Journal of
Cancer Education, 9(1), 46-52.
This article describes the development
of a culturally sensitive, cost-effective
documentary on cervical and breast cancer
targeted to the Latino population. Recent
studies demonstrated that video modalities
are effective in increasing knowledge
and promoting health-protective behavior
in low-income minority populations especially
when they are designed to address the
cultural beliefs of specific races/ethnicities. This
study used a focus group of Latinas to
develop an understanding of the attitudinal
barriers related to cultural values to
breast and cervical cancer screening. Two
Spanish-language videotapes on cervical
cancer prevention and one on breast cancer
were produced that emphasized relevant
cultural dynamics, varied production elements
with entertainment value, including music,
information comprehensible to people with
little formal education, and a short,
moving, minimally didactic presentation. The
article also presents a case study of
the experience of increased demand for
cervical cancer screening that occurred
as a direct result of one video screening. After
showing the video to 27 Latina mothers,
all 27 attendees requested Pap smears. Soon
after, requests numbered 60 from women
informed by “word-of-mouth”
dissemination. The monthly mean number
of Pap smears requested during the following
few months was nearly twice that of previous
years.
Yancey AK, Tanjasiri SP, Klein M, Tunder
J (1995). Increased cancer screening
behavior in women of color by culturally
sensitive video exposure. Preventive
Medicine, 24(2), 142-148.
This article presents the results of
a formal evaluation of a culturally sensitive
health education video intervention conducted
in two community health clinic waiting
rooms. The study was designed to
test the hypothesis that exposure to culturally
sensitive videos in waiting rooms can
influence cervical cancer screening behavior. In
addition, the value of the videotapes
among differing Latino populations was
explored by choosing intervention sites
in different cities. Two community
health clinics were chosen - one in the
Upper West Side of Manhattan in New York
City and the other in West Los Angeles. The
videos were displayed in one or more clinic
waiting rooms using a 1-week-on –
1-week-off study design. Follow up
data was obtained from monthly laboratory
summary reports. Results of the study
show that the proportion of women who
received Pap smears was approximately
one-third higher among those who were
exposed to the video intervention than
among those in the control group at each
clinic.
Diabetes
Luyas GT (1991). An explanatory
model of diabetes. Western
Journal of Nursing Research, 13(6),
681-697.
This study describes the explanatory
model for Type II non-insulin dependent
diabetes used by 19 low-income Mexican
American women who have the disease. Explanatory
models of specific diseases address how
a person talks about disease and relates
to illness as a response to culturally
based life styles.
Oomen JS, Owen LJ (1999). Culture
counts: why current treatment models fail
Hispanic women with Type II diabetes. Diabetes
Education, 25(2), 220-225.
The article looks at the barriers to
care for Type II diabetes among Hispanic
women. The authors suggest that established
health behavior models do not adequately
address the unique needs of the population
and that there is a need for interventions
based on comprehensive, culturally sensitive
models that work with cultural norms.
The article suggests several culturally
sensitive methods for increasing treatment
adherence in female Hispanics with Type
II diabetes, including, determining whether
the patient is using any alternative forms
of care, maintaining open communications
with patient and family, asking direct
questions on follow up visits about treatment
adherence, barriers to compliance, and
possible solutions.
Perez-Stable E, Napoles-Springer A, Miramontes
J (1997). The effects of ethnicity
and language on medical outcomes of patients
with hypertension or diabetes. Medical
Care, 35(12), 1212-1219.
This study looks to fill the gap in research
that has compared the well being functioning
of patients from different ethnic backgrounds
with chronic medical conditions. The study
addresses the question of how cultural
factors affect a patient’s communication
with their physician and as a result influence
health outcomes. To address this question
the study conducts a cross sectional study
of 226 general medicine patients with
hypertension or diabetes to compare the
effect of ethnicity and language concordance
with their physical health outcome measures,
use of health care services, and clinical
outcomes.
HIV/AIDS
DiClemente RJ, Wingwood GM (1995). A
randomized controlled trial of an HIV
sexual risk reduction intervention for
young African American women. JAMA,
274(16), 1271-1276.
This article tests the effect of educational
sessions on HIV risk reduction with African
American women aged 18-29 and represents
the first randomized control trial of
community-based HIV sexual risk reduction
for economically disadvantaged young adult
African American women. Two intervention
groups were created, one that received
five sessions of education and another
that received the same educational material
in one session. The material covered
the following topics: gender and
ethnic pride, knowledge of HIV and risk
behavior, sexual assertiveness and communication
training, proper condom use skills, and
cognitive coping skills. The women
who received the education in one session
showed similar changes in behavior to
those women who did not receive the intervention. However,
the women who participated in the prolonged
intervention were significantly more likely
to have better cognitive skills, interpersonal
skills, partner norms, and consistent
condom use behavior than their counterparts. It
was unclear how much of the prolonged
intervention’s success was based
on African American women peer health
educators and their credibility, communication,
and ability to serve as positive role
models.
O’Connor BB (1996). Promoting Cultural
Competence in HIV/ AIDS Care. Journal
Association of Nurses of AIDS Care, 7
Suppl 1, 41-53.
The article suggests some specific cultural
competence training strategies and offers
a broad conceptual framework for teaching
and learning about the issues involved
in cultural competence, with specific
illustrations relating to HIV/AIDS. According
to the authors, gaining cultural competence
is a developmental process that involves
first, self-awareness and, second, a change
of attitude by the group, peers, and staff
concerning acceptance and flexibility. The
article suggests that optimal, accurate
and effective cultural assessment, must
be carried out not just at the community
or identity-group level but also on a
case-by-case, person by person basis. Additionally
the article addresses the constant need
for providers, especially nurses, to negotiate
between relationships and encounters and
understand the paradox of respecting people’s
values and the customary behaviors that
support those values while working to
change them. The paper briefly concludes
with a discussion of the process of creating
cultural competence through workshops
and training.
Goiceochea-Balbona AM (1997). Culturally
specific health care model for ensuring
health care use by rural, ethnically diverse
families affected by HIV/AIDS. Health
and Social Work, 22(3), 172-180.
The article presents the culturally specific
health model (CSHCM), and illustrates
how an interdisciplinary group formed
to work in partnership with indigenous
providers to respond to HIV crisis in
a rural community. The author describes
the process through which he developed
the model and it’s application to
an outbreak of the AIDS epidemic in Belle
Glade, Florida. The culturally specific
health care model, which serves as a bridge
between research and practice linking
providers with consumers has four features:
1. a culturally specific description of
the target community, 2. a culturally
sensitive approach to assessment and intervention,
3. interdisciplinary collaboration among
providers, and 4. the use of key indigenous
providers. The model is suggested
to guide health social workers in assessing
and intervening with rural, ethnically
diverse families.
Majumdar B, Roberts J (1998). AIDS awareness
among women: the benefit of culturally
sensitive education programs. Health
Care for Women International,
19(2), 141-153.
This study evaluates the effectiveness
of using culturally sensitive train-the-trainer
type activities to increase knowledge
and develop attitudes regarding AIDS in
culturally diverse populations. The
intervention involved training volunteer
facilitators from different community
groups, providing them with knowledge
about HIV and skills to facilitate larger
groups. Each facilitator then convened
sessions through their organizations. Different
facilitators used different facilitation
techniques, varying by race and ethnicity. This
resulted in exposing community participants
to new information and changing attitudes
towards those living with AIDS.
Mental Health/Substance Abuse
Amodeo M, Robb N (1998). Evaluating
outcomes in substance abuse training program
for Southeast Asian human service workers:
problems in measuring change cross-culturally. Journal
of Drug Education, 28(1), 53-63.
The article explores the challenges faced
in cross cultural substance abuse training
programs through the specifics of one
course taught to Cambodian and Vietnamese
human service workers over a two year
period.
Bechtel GA, Davidhizar R, Tiller CM (1998). Patterns
of mental health care among Mexican Americans. Journal
of Psychosocial Nursing and Mental
Health Services, 36(11), 20-27.
An analysis of mental health services
to Mexican Americans using the Giger and
Davidhizar model. The article suggests
three improvements: (1) Extending cultural
care beyond language enhances the use
of mental health services and fosters
a mutually agreed-on plan of care. (2)
Understanding cultural characteristics
facilitates an understanding of behavior,
family and social dynamics, and adaptation
patterns to stress that can empower clients
to work toward their goals and validate
the impact of emotions and behaviors on
others. (3) Culturally appropriate mental
health care reflects a synthesis among
communication, space, social organization,
time, environmental control, and biological
variables.
Capers CF (1995). Mental health
issues and African Americans. Clinics
in Geriatric Medicine, 11(1),
1-13.
The article provides a brief overview
of the issues of older African Americans,
as a basis for discussion about specific
concerns regarding diagnostic bias surrounding
mental health issues. The conceptual model
of Cultural Competence in Psychiatric
Mental Health Nursing is used to organize
the information presented, however, the
model is also critiqued. Suggestions for
the provision of culturally competent
psychiatric care are provided.
Center for Mental Health Services (1996
June). Managed care and ethnic
minorities: Working group to develop an
education agenda. Prepared for
Substance Abuse Mental Health Services
Administration, Department of Health and
Human Services. Washington, DC.
This article represents the efforts of
a workgroup to develop an evaluation agenda
to improve mental health and substance
abuse service to African Americans, Asian/
Pacific Islanders, Latino, and Native
Americas. The paper explores a set
of values that promotes the success of
ethnic minorities in order to maximize
the benefits of managed care and suggests
standards for broad evaluation areas. Working
group members defined ten key areas for
assessment: information systems,
economics and finance, systems structure,
human resources, clinical quality/ standards
of care, service design, regulations,
community norms, consumers/caregivers,
and access. Furthermore, the group
devised recommendations for continued
efforts that support improvement of mental
health services for ethnic minorities. These
include: promoting collaboration among
key stakeholders, encouraging follow-up
insuring that the evaluation agenda developed
is incorporated in ongoing discussions
of managed care for people with mental
illnesses at the federal, state, and local
levels, adopting a market strategy through
educating managed care organizations about
the cost-effectiveness of providing appropriate
mental health and substance abuse services
to ethnic minorities, convening a regional
or national conference, and continuing
the dialogue to keep the needs of ethnic
minorities in the forefront of the conversation
about managed care.
Comas-Diaz L, Jacobsen FM (1995). The
therapist of color and the white patient
dyad: contradictions and recognition. Cultural
Diversity and Mental Health,
1(2), 93-106.
The therapist of color and white patient
dyad often involves contradictions and
recognitions that are acknowledged through
the specific processes and dynamics permeating
this dyad. The relationship between self
and other is frequently mediated through
projection and identification. This article
examines this unique interracial and interethnic
therapeutic dyad emphasizing its clinical
implications through the attribution of
otherness, the use of colored screen projection,
and the significance of power reversal.
Finley LY (1998). The cultural context:
families coping with severe mental illness.
Psychiatric Rehabilitation Journal,
21 (3), 230-240.
This article provides an overview of
the unique needs of families from different
ethnic and cultural backgrounds coping
with a member with severe mental illness
and of research on coping mastery among
ethnic caregivers. Examples of alternative,
and innovative culturally compatible approaches
to enhance partnership, and support of
families are described. Specifically,
the article recommends that “family
support” and the design of innovative
support models occur within the context
of the family’s culture and are
mediated by factors such as family background,
ethnicity, ethnic identity, cultural affiliation,
socioeconomic status and acculturation.
The authors suggest there is a need for
exploration of unique methods that explore
the strengths of ethnic families and how
culturally adaptive styles might be used
effectively in working with different
ethnic groups. The author addresses
guidelines, approaches and different models
for providing support to multicultural
families.
Herrick CA, Brown HN (1998). Underutilization
of mental health services by Asian-Americans
residing in the United States.
Issues in Mental Health Nursing,
19(3), 225-240.
The article examines the need for planning
appropriate culturally competent mental
health services for Asian-Americans, a
group noted for less use of these services
than other populations. A model for cultural
competence can provide a framework for
psychiatric nurses and other mental health
professionals (MHPs) to become more aware
of Asian-American values and beliefs and
provide more culturally sensitive care.
Awareness tools are included to guide
MHPs in determining whether culturally
competent care is available locally to
meet the needs of this underserved population.
Malgady RG, Roglet LH, Costantino G (1990). Culturally
sensitive psychotherapy for Puerto Rican
children and adolescents: a program of
treatment outcome research. Journal
of Consulting and Clinical Psychology,
58(6), 704-12.
This article evaluates treatment outcomes
of a program that attempts to introduce
culture into therapy with Puerto Ricans
that target anxiety symptoms, acting-out
behavior, and self-concept problems. Evaluation
of outcomes confirmed the impact of culturally
sensitive modeling therapy on anxiety
symptoms and other selected target behaviors,
but negative treatment effects also were
also evident. Results suggest that new
approaches to psychotherapy for special
populations, such as Hispanic children
and adolescents, should be buttressed
by programmatic research oriented toward
the comparative evaluation of treatment
outcomes and should be attuned to therapeutic
processes mediating between culture and
outcome.
Morris TM (1990). Culturally sensitive
family assessment: an evaluation of the
family assessment device used with Hawaiian-American
and Japanese-American families. Family
Process, 29 (1),105-16.
This article reports the results of a
study of the McMaster Family Assessment
Device (FAD) used with samples drawn from
two non-Anglo ethnic groups: Hawaiian-Americans
and Japanese-Americans living in Hawaii.
Results suggested that cultural norms
regarding family functioning may vary
according to socioeconomic status.
Western Interstate Commission for Higher
Education (WICHE) Mental Health Program
(1997 December). Managed
care and cultural competency in the delivery
of mental health services. Prepared
for the Center for Mental Health Services,
Substance Abuse and Mental Health
Services Administration, Department of
Health and Human Services.
The article summarizes the efforts of
four National Racial/Ethnic Panels on
Cultural Competence in Managed Care Health
Services. Each panel developed ethnic-specific
services, system and clinical standards,
and provider competencies. The document
also includes a strategic plan for implementing
the cultural competence standards for
delivery of services across the four racial/
ethnic groups, addressing specific initiatives
that would facilitate successful implementation
of standards. Additionally the WICHE
Mental Health Program completed a survey
of eleven Western states concerning changes
in the public mental health system to
identify a number of trends, including
the response of managed care to service
needs of racial/ ethnic populations.
Western Interstate Commission for Higher
Education (WICHE) Mental Health Program,
National Latino Behavioral Health Workgroup
(1997 December). Cultural
competence guidelines in managed care
Mental health services for Latino populations. Prepared
by the Center for Mental Health Services,
Substance Abuse and Mental Health Services
Administration, Department of Health and
Human Services.
The authors frame guiding principles
and guidelines in response to opportunities
for delivery of improved behavioral services
to the Latino population under managed
care. The report includes two sets
of guidelines. One set of guidelines
addresses non-clinical aspects of the
health care delivery system, such as cultural
competence planning, governance, benefit
design, quality monitoring and improvement,
decision support and management information
systems, staff training and development,
and provider competencies. The second
set are clinical in nature focusing on
access to care, triage and assessment,
care planning, treatment services, case
management and linguistic support. For
each set of guidelines, the authors provide
an objective, guidelines to meet the objective,
recommended performance indicators and
recommended outcomes.
Working Groups on Cultural Competence
in Managed Mental Health Care (1997 October). Cultural
competence standards in managed mental
health care for four underserved/underrepresented
racial/ethnic groups, final report. Center
for Mental Health Services, Substance
Abuse and Mental Health Services Administration,
Department of Health and Human Services.
Washington, DC.
This article represents the culmination
of separate and collaborative efforts
of four national panels to develop cultural
competence standards for mental health
services for African Americans, Asian/Pacific
Islanders, Latino/Hispanic, and Native
American/American Indian/Native Alaskan/Native
Hawaiian. The panels developed a
set of principles underlying cultural
competence, a definition of cultural competence,
and standards for provider competencies. In
terms of the health care system (e.g.,
health plans and public sector), they
developed standards for planning, governance,
benefit design, prevention/education/outreach,
quality monitoring and improvement, decision
support and management information systems,
and human resource development. For
clinical care, they developed standards
for access and service authorization,
triage and assessment, care planning,
plan of treatment, treatment services,
discharge planning, case management, communication
styles and cross cultural linguistic and
communication support, and self help. In
terms of provider competencies, they assert
that providers should have knowledge and
understanding of consumer populations’
backgrounds, clinical issues for different
ethnic groups and sub-groups, how to provide
appropriate treatment, agency and provider
roles. They also assert the providers
should have the knowledge and skills to
communicate effectively across cultures,
provide quality assessments, formulate
and implement quality care and treatment
plans, provide quality treatment, and
demonstrate respectful attitudes.
Women’s Health and Maternal
and Child Health
Dickinson CP, Jackson DJ, Swartz WH (1994). Making
the alternative the mainstream: Maintaining
a family centered focus in a large freestanding
birth center for low-income women. Journal
of Nurse Midwifery, 39(2), 112-118.
This article analyzes the BirthPlace,
a successfully “mainstreamed”
alternative to maternity care program
focused around the needs of the low-income
Hispanic population in San Diego. The
BirthPlace program primarily serves a
public-funded, Hispanic population, with
certified nurse-midwives as the primary
providers. The BirthPlace program primarily
serves a public-funded, Hispanic population,
with certified nurse-midwives as the primary
providers.
Doswell WM, Erlen JA (1998). Multicultural
issues and ethical concepts in the delivery
of nursing care interventions. The
Nursing Clinics of North America,
33(2), 353-61.
This article uses a case study to describe
a process that health care providers can
use when faced with ethical dilemmas that
arise when caring for patients from different
cultures. Nursing strategies to promote
culturally sensitive care are discussed,
and include cultural assessment, heightening
sensitivity to ethical issues in cultural
diversity, and the role of continuing
education in providing culturally competent
care.
Maternal and Child Health Bureau (1991).
Improving services for culturally
diverse populations; MCHB’s
division of services for children with
special health needs activities, FY 1990-1991.
Bureau, Health Resources and Services
Administration,
Department of Health and Human Resources.
Washington, DC.
This article reiterates MCHB’s
Division of CSHN’s commitment to
cultural competence and describes demonstration
grants focused on specific groups and
National MCH Center efforts. Activities
grantees undertook to promote cultural
competence can generally be grouped under
outreach, identifying cultural barriers,
providing cultural training, recruiting
and hiring bilingual staff, including
family in decisions, developing interstate
coalitions, translating and using less
medical and professional jargon
Im EO, Meleis AL, Lee KA (1999). Cultural
competence of measurement scales of menopausal
symptoms: use in research among Korean
women. International Journal
of Nursing Studies, 36(6), 455-463.
In this paper, cultural competence of
the scales measuring menopausal symptoms
were examined and critically analyzed
for the limitation in research when applied
to a population that the model was not
developed for, Korean women. The study
suggests that the validation of questions
included in measurement scales though
focus groups, explorations, and use of
open ended questions, attention to language
use, and knowledge of linguistic nuances
need to be incorporated in pilot studies
to enhance the development and use of
culturally competent questions. Additionally
pilot studies must look at the adequacy
of terms, cultural stereotyping of responses,
and its impact on symptom reporting, and
appropriateness of communication styles
need to be carefully examined.
Mattson S (1995). Culturally sensitive
perinatal care for Southeast Asians. Journal
of Obstetric, Gynecologic, and Neonatal
Nursing , 24(4), 335-41.
The authors explore the specific considerations
that need to be addressed when providing
care to southeast Asians in the United
States and Canada. The article looks
at refugees’ lifestyle and health
problems, barriers to care, traditional
healing practices, and the Southeast Asian
Health Project, a program specifically
designed to respond to the need for maternal
and child care of a Southeast Asian community
in the United States.
Naish J, Brown J, Denton B (1994). Intercultural
consultations: investigation of factors
that deter non-English speaking women
from attending their general practitioners
for cervical screening. British
Medical Journal, 309(6962), 1126-1128.
This paper presents the results of a
study that examined the factors that deter
ethnic minority women living in London
from visiting their general practitioner
for a Pap smear. The study used 11
focus groups, each with a total of six
to ten women. Results showed that
women reported that administrative and
language barriers were more important
than anxiety over the results of the test. The
findings have several practice implications:
(1) ethnic minority women are accepting
of cervical cancer screening once the
procedure is understood; (2) inadequate
administration and language are potential
barriers to screening; (3) concerns about
surgery hygiene, sterility of equipment,
and facilities for children deter women
from treatment; and (4) focus groups using
the patients’ own language were
an effective way to consult with ethnic
minority community groups.
Nelkin VS (1994). Implementing
the Surgeon General’s action agenda: To
improve access to care and quality of
life for all children with special health
needs and their families, survey of SPRANS/
MCHIP grantees. Maternal
and Child Health Bureau, Health Resources
and Services Administration, Department
of Health and Human Services. Washington,
DC.
This article represents the findings
from a survey of SPRANS/MCHIP direct service
grantees who work with children with special
health care needs, including demonstration
grantees and National MCH Centers. The
report examines cultural competence and
the Surgeon General’s six action
steps to improve access to care and quality
of life for CSHCN: family-centered
care, community-based care, provider preparation,
coalition building, cost controls, adequate
financing, and research and dissemination. Of
the respondents, 93% were implementing
family-centered care and community-based
care, 80% were implementing provider preparation
activities, 78% were implementing coalition
building, 71% were implementing research
and dissemination, 63% were implementing
culturally competent care and cost controls,
and 54% were implementing adequate financing. Indicators,
and examples of how to make progress for
those indicators, were provided for each
of the action steps.
Pearce CW, Hawkins JW, Carver-Chase D,
Ebacher R, Matta S, Sullivan A, Vawter
VJ, Vincent C, Windle KA (1996). Comprehensive
interdisciplinary care: making a difference
in pregnancy outcomes for Hispanic women. Public
Health Nursing, 13(6), 416-424.
This article reports on a cohort study
that looks at the prenatal care received
by 113 Hispanic women in a Northeast city. The
outcomes of the study demonstrate a need
for a model of care that is comprehensive,
culturally sensitive, and encourages women’s
self care during pregnancy. The authors
cite their study as evidence supporting
the work of other researchers that recommend
consideration of cultural variations in
women’s view of prenatal care when
developing programs.
Randall-David E (1997 June). Strategies
for working with culturally diverse communities
and clients. Hemophilia
Program, Maternal and Child Health Bureau,
Department of Health and Human Services. Washington,
DC.
This manual is designed as a workbook
to help the health care provider increase
their understanding of the cultural aspects
of health and illness so that they can
work effectively with individual clients
and families from culturally diverse communities. It
provides tools for providers to assess
their own cultural heritage and to learn
about the cultural values, beliefs and
practices of the community they serve.
The manual also provides guidelines for
working with culturally diverse community
groups and for using interpreters and
other vehicles to enhance cross-cultural
communication. Additionally there
is a bibliography and various appendices
that contain additional assessment tools
and resources.
State CSHCN Title V Directory Workgroup
(1990). Improving state services
for culturally diverse populations.
Maternal and Child Health Bureau, Health
Resources and Services Administration,
Department of Health and Human Services.
Washington, DC.
This article represents the work of a
group of State Directors of CSHCN programs
in 1990 to assess and improve service
delivery for culturally diverse populations
within their programs in the context of
family-centered, community-based, culturally
sensitive, coordinated care. The
group developed recommendations to be
implemented at the federal and state levels
and defined critical components of culturally
competent programs, such as collection
of data on cultural groups in the state
to identify their ethnicity, location,
and gaps in services, family strengths,
and needs, development of clear policy
statements about cultural competence,
committed outreach to identify children
and families who need services, family
and community involvement in developing
and implementing policies and procedures,
development of specific job descriptions
for staff who work with children with
special needs and their families of diverse
cultural groups, training in cultural
sensitivity and the concepts of culturally
competent systems of care for agency staff
and volunteers, coordination of services
and case management at the community level
that is appropriate for diverse populations,
strong policies and clear procedures to
protect clients, reorganization of systems
to meet the needs of all children and
their families, and interstate collaboration
to promote continuity in family-centered,
community-based, culturally competent,
coordinated systems of care for children
with special health care needs and their
families.
[1] The areas of “assessment
tools and evaluative models” and
“performance measures and/or indicators”
are organized into separate sections.
This was done in order to distinguish
between those documents that were consulted
in developing a conceptual model of cultural
competence and those consulted in identifying
performance indicators and/or measures
of cultural competence. There is some
overlap of citations between these sections.
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