Section IV: Conclusion
A. Review
of findings from the literature
This literature review report reflects
an analysis of over 120 works in the field
of cultural competence in health care
and forms the basis for the development
of a measurement profile for cultural
competence in health care delivery settings. The
literature reviewed includes seminal works
that illuminate core concepts of cultural
competence, as well as other literature
examining specific assessment protocols
or program and condition-specific issues. In
analyzing this literature, The Lewin Group
identified a preliminary set of nine domains
for measuring cultural competence that
emerged as core clusters from the array
of theoretical and methodological concepts
and approaches presented in the literature.
For each domain, specific indicators
and measures were also identified from
the literature. In reviewing the indicators
and measures identified in the literature
and their linkage with particular domains
and topic areas, there was evidence of
differing representation of measures by
type of measure and across various domains
and topic areas. In terms of measure type,
the majority of measures in the literature
can be classified as process oriented,
with far fewer falling into the category
of outcome/impact. The abundance
of process measures and paucity of outcome/impact
measures may be due to a variety of factors,
including a lack of infrastructure to
support data collection on outcomes. Process
measures typically reflect the operational
functioning of an organization and, hence,
may represent data already being collected
by an organization. The collection of
outcome/impact measures often requires
more sophisticated data collection techniques,
additional resources, and may be impeded
by privacy and confidentiality concerns.
The lack of outcome/impact measures may
also be due to the difficulty in parsing
out the contribution of cultural competence
to ultimate outcomes relative to other
factors.
Measures were identified for almost
all of the domains, with the exception
of cultural sensitivity. Cultural sensitivity,
though stressed in the core models and
methods literature, was the least represented
in the collection of health system measures. It
is unclear to what extent this represents
an actual gap in the field of study or
points to overlap in how measures are
constructed. It may be the case that
the domain of cultural sensitivity and
its attendant topic areas are imbedded
or captured adequately through other domains.
In general, the review and analysis
of the literature highlighted critical
elements to be measured in health care
delivery setting and potential areas for
measurement. However, while the literature
contains many examples of standards and
guidelines that can be translated into
performance measures, as well as tools
that can be used in assessing cultural
competence in various health care delivery
settings, the literature containing tested
and validated measures of cultural competence
is limited. This lack of validated
and broadly applied measures represents
a significant challenge for the further
development of a measurement profile.
B. Implications
for developing a measurement profile
While the
literature review provided support for
what constitutes the critical elements
(i.e., domains) of cultural competence,
in order to further refine and develop
a measurement profile of cultural competence,
the field must move beyond conceptualizing
cultural competence to applying and testing
actual measures of cultural competence
in real-world settings. Before an empirically-tested
measurement profile can be developed,
several challenges need to be considered,
both generic to measurement and specific
to measuring cultural competence.
| Measurement
Challenges Specific to Cultural Competence |
- Fluid and multi-faceted
nature of culture and cultural
competence: Culture is
typically characterized as a monolithic,
unitary phenomenon that remains
stable over time and homogenous
within different social groups.
However, in actuality both culture
and cultural competence are fluid
and dynamic constructs and processes.
This may pose a dilemma for measuring
cultural competence given the
requisite concreteness of measurement
and the fluid nature of cultural
competence.
- Complexity of culture
and cultural competence:
Along with the issue of fluidity
is the need to consider the complex
nature of culture and cultural
competence. Culture and cultural
competence as multi-faceted constructs
will require a measurement approach
that captures not only fluidity,
but also its relationship to and
interaction with an individual,
organization, health care delivery
system, and society.
- Attribution:
Cultural competence is an essential
component of a larger set of variables
important for improving access,
eliminating health disparities
or impacting other types of outcomes.
Due to the multiplicity of factors
that influence these outcomes,
it becomes difficult to parse
out the contribution of cultural
competence in the larger context
of other factors.
|
| General
Measurement Challenges |
- Organization’s
appreciation of the value of measurement:
One of the key challenges to measurement
is garnering the organizational
will to pursue activities around
measurement. Organizations must
first recognize the value of measurement
and view it as an integral component
of their operational functioning.
Without “buy-in” from
every level of an organization
as to the importance of measurement,
forward momentum may be stalled
and derailed.
-
Data
availability and feasibility:
While a measure may be deemed
important for measurement, without
an existing data source further
progress is delayed. A
corollary data challenge in
measurement is the issue of
feasibility. Data collection
may not be feasible due to the
burden associated with additional
staffing requirements and available
financial resources.
- Baseline data:
Related to the issue of data availability
and feasibility is the lack of
adequate baseline data to support
measurement. Baseline data and
an adequate assessment of the
current environment are necessary
for setting targets and assessing
change and impact. Without adequate
baseline data, the timeline for
proceeding with measurement may
be delayed until additional resources
are identified to collect it.
-
Capacity
of health care delivery organizations
for measurement:
Many organizations are not
equipped to invest in measurement.
Organizations may lack the
infrastructure needed to engage
in measurement activities,
such as information technology,
dedicated staff, record keeping,
etc. It may be necessary for
organizations to do an internal
scan of their capacity to
engage in measurement efforts
and either identify, direct
or re-direct the necessary
resources.
-
Instrumentation
and tools: The evolution
of more sophisticated measures
must coincide with the evolution
of appropriate instrumentation
and tools. Existing measurement
tools may not be able to capture
the nuances of specific measures.
Various tools such as surveys
and interviews have inherent
limitations that may impact
their usefulness for measuring
difficult concepts within cultural
competence.
-
Short
term versus longitudinal measurement
issues: In assessing
the value of process versus
outcome types of measures, many
prefer outcome measures because
of their potential to demonstrate
direct and concrete impacts
of various activities. However,
while outcome measures may be
preferred, they are much more
difficult to measure and their
impact may not be readily identifiable
in the short term. The use of
outcome measures may require
longer time horizons to demonstrate
impact.
|
The purpose of this literature review
report and the overall HRSA project is
to serve as a building block for advancing
the practical understanding of how to
measure cultural competence in health
care settings. An important next
step includes refining the identified
domains and identifying areas where domains
and topic areas could be collapsed. Important
next steps toward assessing the feasibility
and practical application of potential
measures include identifying: a limited
core set of indicators/measures; ways
to translate and apply these measures
in health care settings; potential data
sources and approaches for obtaining information
on these indicators and measures; existing
and needed instruments and tools for gathering
information on the identified indicators
and measures of cultural competence; and
the infrastructure necessary to support
measuring cultural competence in health
care delivery settings. Gathering information
from health care delivery settings on
the appropriateness and feasibility of
the measurement profile will advance the
science of measuring cultural competence
in health care delivery settings by addressing
the question, "How do we know cultural
competence when we see it?"
|
