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


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.


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.


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.


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.