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


Section II:  Conceptualizing Cultural Competence and Identifying
Critical Domains

I.  Conceptualizing Cultural Competence and identifying critical Domains

Based on the literature review, this section reports on the current state of the field in conceptualizing cultural competence and identifies key domains or areas for measuring cultural competence.  This section also provides a synthesis of the literature that provides a basis for each of the domains identified by the project team.  A full annotation of the articles reviewed for this analysis can be found in the bibliography at the end of this document.

A.     Approaches to conceptualizing cultural competence

Many health care professionals agree that cultural competence is a critical factor in providing relevant services to the nation’s growing culturally and ethnically diverse patient population.  An extensive body of literature exists that describes the evolution of cultural competence in the context of health care.  The following discussion primarily focuses on this body of work, recognizing that literature outside of the health care sphere (e.g., social marketing, anthropology, communication and media, etc.) could also enhance the understanding of cultural competence in health care.  While many articles addressing the concept of cultural competence were reviewed, the project team identified five central works.  The authors of these five works are Cross, T.L.,  Bazron, B.J., and Isaacs, M.R, Campinha-Bacote, J., Carballeira, N., Leininger, M., Davidhizar, R., and Giger, J.N. These works were chosen as seminal literature because of their scope and substance, their frequent citation in the literature, and the consensus validation of their ideas and perspectives in works of many other authors.

The literature provides health care professionals with several definitions of cultural competence and numerous methods for providing culturally competent care.  For the purpose of this review, we use the definition of cultural competence set forth by Cross, T.L., Bazron, B.J., Dennis, K.W., Isaac, M.R., and Campinha-Bacote, J.1, 2  Cultural competence is “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.”1

The literature on cultural competence approaches the issue of competence in two ways: theoretical and methodological.  For example, Cross, et al. and Campinha-Bacote offer a theoretical approach in which cultural competence is seen as a process or continuum whereby an individual’s view of other cultures transforms from destructive or unaware to proficient.3  Cross, et al. define a set of factors that must be present in order to progress along the continuum. There are six possible points along this continuum:

1.      Cultural destructiveness,
2.      Cultural incapacity,
3.      Cultural blindness,
4.      Cultural pre-competence,
5.      Cultural competence, and
6.      Cultural proficiency.

Furthermore, Cross, et al. describe several conditions that must exist in order for professionals to move along this continuum.  Professionals must: value diversity, understand their cultural biases, be conscious of the dynamics that occur when cultures interact, internalize cultural knowledge, and develop adaptations to diversity.  Each of these conditions set by Cross, et al. must function at every level of the health care system in order for that system to provide culturally competent care.

Similar to Cross, et al., Campinha-Bacote views cultural competence as a process, not an endpoint, in which health professionals continually strive to work within the cultural context of the patient.3  The process requires health care providers “to see themselves as becoming culturally competent rather than being culturally competent.”1  Although Campinha-Bacote does not define points in this process of becoming, the author does outline five components of cultural competence similar to the five essential elements presented by Cross, et al.  The five components of competence include:

1.      Cultural awareness,
2.      Cultural knowledge,
3.      Cultural skill,
4.      Cultural encounters, and
5.      Cultural desire.

Health care providers can work on any one of these constructs to improve the balance of all five, but eventually all five constructs must be experienced and addressed.  Campinha-Bacote explains that the intersection of these constructs represents the process of cultural competence, and as the area of intersection becomes bigger, health care providers will internalize cultural competence at a deeper level and provide higher quality care.

Authors such as Carballeira, Leininger, and Davidhizar and Giger offer a more methodologically driven approach that focuses on the methods a professional might use in order to become culturally competent and provide culturally competent care. 4, 5, 6  These authors typically assume that cultural competence is a goal that can be reached when a skill set is learned with the proper training.       Text Box: Approaches to Conceptualizing Cultural Competence A large body of knowledge exists regarding ways to think about cultural competence. The following authors are highlighted because of their scope and substance, their frequent citation in the literature, and the consensus validation of their ideas and perspectives in the works of many other authors:
Cross, Bazron, and Isaacs discuss how the process of cultural competence progresses along a continuum that ranges from cultural destructiveness to proficiency. Campinha-Bacote outlines five components of cultural competence: awareness, knowledge, skill, encounters, and desire.
Carballeira introduces the LIVE & LEARN model where LIVE stands for Like, Inquire, Visit, and Experience, while LEARN stands for Listen, Evaluate, Acknowledge, Recommend, and Negotiate. Leininger describes a Sunrise Model that includes seven dimensions:
1. Cultural values and lifeways,
2. Religious, philosophical, and spiritual beliefs; ,
3. Economic factors,
4. Educational factors,
5. Technological factors,
6. Kinship and social ties, and 7. Political and legal factors. Davidhizar and Giger present a model of transcultural assessment that examines:
1. Communication,
2. Space,
3. Time,
4. Social organization,
5. Environmental control, and 6. Biological variations.D-link

Specifically Carballeira depicts the interaction between a provider and a client as a cross-cultural exchange of attitudes. 7  The author suggests that in a health care setting, the patient simply reacts to the provider’s “cultural attitude.”  Similar to the Cross, et al. and Campinha-Bacote continuum models, Carballeira proposes that the provider’s cultural attitude falls within a range: superiority, incapacity, universality, and sensitivity, to competence.  Additionally, Carballeira explores the patient’s reaction to the provider where the client’s reaction ranges from resistance to accommodation to adaptation.  The author suggests the use of the LIVE & LEARN model which presents providers with a practical, phased approach to cross cultural service delivery that respects client centrality, avoids stereotyping, and leads to the adoption of mutually acceptable objectives and measures for changed behavior.  In this model, the acronym “LIVE” stands for Like, Inquire, Visit, and Experience, while “LEARN” stands for Listen, Evaluate, Acknowledge, Recommend, and Negotiate.

Leininger’s Sunrise Model provides a method for assessing patients in order to provide comprehensive and culturally sensitive care.4  Leininger believes that the Western medical model fails to explore cultural patterns of illness.  The Sunrise Model suggests that the world view and social structure of the client are important areas to investigate and can be explored using seven dimensions:

1.      Cultural values and lifeways,
2.      Religious, philosophical, and spiritual beliefs,
3.      Economic factors,
4.      Educational factors,
5.      Technological factors,
6.      Kinship and social ties, and
7.      Political and legal factors.

Health care professionals must develop the skills, knowledge, and patience to explore and validate what the patient says and does.  Once information is obtained for each of the dimensions, health care professionals can guide patient treatment and interventions. According to this Sunrise Model, providers should base their selection of a treatment approach or combination of approaches on information gathered from the assessment. Leininger suggests that this guidance can occur in a variety of ways: cultural care preservation and/or maintenance, cultural care accommodation and/or negotiation, and cultural care repatterning and/or restructuring.

Davidhizar and Giger also present a transcultural assessment model to assist health care professionals in assessing patients from diverse cultures that focuses on six factors: 6

1.      Communication,
2.      Space,
3.      Time,
4.      Social organization,
5.      Environmental control, and
6.      Biological variations.

According to Davidhizar and Giger, health care professionals should receive training on how to use these factors to assess the health beliefs and practices that may have a significant impact on how an individual responds to treatment and patient education.  Using this assessment model will assist health care professionals in providing care that is sensitive and tailored to the needs of culturally diverse individuals.

The various approaches to conceptualizing cultural competence identified in the literature stress the importance of viewing cultural competence as a dynamic process involving continual progression and involvement of all levels of the health care system. The literature identifies essential elements and conditions that must be present in the health care system in order to support cultural competence. These essential elements will provide a basis for identifying domains for measuring cultural competence, as discussed in the Section II. B of this report.


B.     Critical domains for measuring cultural competence                                    Text Box: Critical Domains for Measuring Cultural Competence Analysis of the conceptual and other literature led to the extrapolation of nine domains that provide a basis for developing a measurement profile. Values and attitudes refer to beliefs held by healthcare professionals, organizations that influence health care delivery. Cultural sensitivity denotes the providers heightened awareness and can be a precursor to changing values, attitudes, and behaviors. Communication encompasses the variety of ways that describe how the exchange of information among those involved in care delivery occurs. Policies and procedures consist of the programmatic and planning vehicles through which organizations can facilitate the provision of culturally competent care. Training and staff development concentrate on providing professionals with the requisite knowledge and skills to supply culturally competent care. Facility characteristics, capacity, and infrastructure focus on access and availability of care and the environment in which it is provided, including location, physical resources, and information systems. Intervention and treatment model features includes evaluation, diagnosis, treatment, and referral and how culture-specific knowledge and sensitivity can enhance them. Family and community participation recognizes the role of the family and community in achieving quality health care. Monitoring, evaluation and research includes activities to assess progress in cultural competence efforts as well as to create and disseminate new knowledge. Areas of overlap exist where topic areas align with several domains. These areas of overlap are highlighted in Section II.C.D-link

The conceptual literature discussed in the previous section and other literature reviewed later in this document suggest that cultural competence in health care settings must be evidenced or manifested in a broad range of spheres or areas.  The project team has preliminarily identified nine such areas that are potentially important to the development of a measurement profile for cultural competence in health care settings. These areas are referred to here as domains, and include:

1.      Values and attitudes,
2.      Cultural sensitivity,
3.      Communication,
4.      Policies and procedures,
5.      Training and staff development,
6.      Facility characteristics, capacity, and infrastructure,
7.      Intervention and treatment model features,
8.      Family and community participation, and
9.      Monitoring, evaluation and research.

Within these global domains, many specific subjects or topic areas were identified as characterizing the domain and forming the particular focus or substantive content for which indicators and measures might be identified and developed.  These topic areas are discussed in Section II. C of this report.  In this section of the report, the nine domains are defined with regard to providers’/health care organizations’ cultural competence and discussed with respect to the domains’ linkage to the key conceptual literature.

Domain 1:  Values and attitudes

Values and attitudes refer to the set of beliefs and mindsets possessed by providers, administrative staff, health care organizations and others involved in service delivery.  The discussion of values and attitudes in the conceptual literature is intertwined with discussions of cultural sensitivity (see below).  The conceptual literature emphasizes training, assessment, and cultural encounters in order for providers to increase the awareness of the values and attitudes they bring to the consumer-provider interaction.  Cultural encounters also increase providers’ ability to understand those that consumers bring with regard to health, medical treatment, and authority.  In other words, provider values and attitudes toward other cultures can change through cross-cultural interactions with clients and by developing knowledge about and adaptation to this diversity.  Leininger’s theory requires health care professionals to evaluate, acknowledge, and develop respect for the cultural differences.  This can be accomplished through active listening, open-ended questions, and a nonjudgmental attitude toward the differences that are encountered.  Carballeira stresses the importance of the provider’s “cultural attitude” and describes a range of attitudes, from “superiority” to “competence.”  At the “competence” level, the provider can respect client centrality, avoid stereotyping, and adopt mutually acceptable objectives and measures for changed behavior.

Domain 2:  Cultural sensitivity

Cultural sensitivity generally refers to heightened awareness and complements several other domains, most notably communication. While values and attitudes refer to the beliefs held by health care professionals, cultural sensitivity refers to heightened knowledge of the needs of the client. Often, cultural sensitivity manifests itself in a provider’s ability to accurately interpret and respond to non-verbal or other cultural cues or in the way in which health care organizations provide information to their clients. This sensitivity can lead to the behavioral adaptations needed for cultural competence. For example, Cross, et al. and Campinha-Bacote both view cultural competence as a continuum.  As a person moves along the continuum, their values and attitudes undergo a transformation from a state of ignorance to one of competence.  However it is also possible for an individual to be culturally aware, and not change behaviors to become culturally competent.

Domain 3:  Communication

Communication encompasses a wide range of activities, both oral and written, that describe the flow and exchange of information among those involved in the provision and receipt of care, including interpersonal exchanges and exchanges between individuals and organizations.  Cultural factors affect the consumer-provider communication.  Cultural competence leads to actions creating concordance in communication styles and increasing the availability and accessibility of language services (e.g., interpretation and translation) to improve communication.  Improved communication can lead to increased consumer satisfaction as well as an improved understanding of and compliance with diagnoses and treatment regimens. From a conceptual perspective, Davidhizar and Giger focus heavily on communication as a key tool for improving cultural competence in their theory of transcultural assessment.  Providers must assess the patient’s communication style to learn about cultural-specific cues that are used.  For example, an understanding of these communication cues can assist the provider in explaining procedures and instructions.

Domain 4:  Policies and procedures

Policies and procedures refer to the programmatic and planning vehicles through which organizations can facilitate the provision of culturally competent care.  Specifically, this includes mechanisms, such as conflict resolution processes and hiring procedures, as well as other devices that operate primarily in managed care settings, such as the breadth of provider networks and types of incentive systems.  Cross, et al. discuss policies and procedures in the context of their continuum of care.  As an agency or professional moves toward cultural competence, they begin to understand the interplay between policy and practice and are committed to policies that enhance services to diverse clientele.  Those that are culturally blind (a mid-point along the continuum) may believe that they are implementing culturally competent policies when, in fact, their policies may be discriminatory and ultimately restrict access to services. When an agency or professional reaches cultural proficiency, policies are flexible and culturally impartial.

Domain 5:  Training and staff development

Training and staff development concentrates on how to provide health care professionals the knowledge and skills required to supply culturally competent care.  An understanding of providers’ individual skill and knowledge level represents a starting point from which to develop programs and curricula to develop cultural competence among health care providers and other staff in health care settings.  Conceptually, the literature often presents training and professional development in the context of interventions and treatment.  However, the domain also addresses the training that happens in academic institutions.  Campinha-Bacote, Carballeira, Leininger and Davidhizar and Giger agree that health professionals should be trained to collect relevant cultural data when conducting health histories and assessments.  Although training and staff development potentially constitutes a topic area within policies and procedures, numerous training efforts profiled in the literature as well as the conceptual emphasis on its importance led to its categorization as a separate domain.

Domain 6: Facility characteristics, capacity, and infrastructure

Facility characteristics, capacity, and infrastructure refer to issues related to the access and availability of care and the environment in which it is provided, including location, hours of operation, physical resources, and information systems.  Often, these issues influence consumers’ experiences in a health care delivery setting and can hamper their capacity to access it.  Cross, et al. address this issue when discussing the influence of an organization’s infrastructure on its ability to be culturally competent.  An organization in seeking to become culturally competent can address the needs of different cultures by developing service models that are adapted to the cultural-specific needs of the population.

Domain 7: Intervention and treatment model features

Interventions and treatment model features focus on aspects of patient evaluation, diagnosis, treatment, and referral services.  These can include how traditional healing beliefs interrelate with the Western medical model, ethnopharmacology, inclusive decision-making, care coordination, and, in a managed care context, health benefit design.  Conceptually, Campinha-Bacote, Carballeira, Leininger and Davidhizar and Giger discuss how culturally competent evaluation of consumers can assist providers in planning interventions and treatments.  Basing diagnoses on a cultural assessment that is sensitive to the cultural needs and beliefs of the patient and sharing it with consumers in a culturally sensitive manner can contribute to consumers’ increased understanding of diagnoses and treatment.  This increased understanding is a step towards improving compliance with a treatment regimen and addressing consumers’ health concerns.  To truly address issues of intervention and treatment providers must understand the epidemiological profile of the client base.

Domain 8:  Family and community participation

Family and community participation refers to family centered, family focused, and family-oriented care that recognizes the important role of the family and the larger community in the provision of health care.  Community participation in assessments and community outreach efforts represent means for providers to develop an understanding of consumers’ cultural backgrounds and support structures and to include these perspectives into policy planning and development and other activities. The extent to which the health care system considers and incorporates input from a broader unit than the direct client influences the degree to which consumers and providers engage in culturally competent discourse.  Both Leininger and Davidhizar and Giger stress that a cultural assessment of a patient should explore the social organization or kinship and social ties of the patient.  This includes involving the family and/or community members when appropriate.

Domain 9:  Monitoring, evaluation and research

Efforts to become culturally competent include monitoring and evaluating current efforts in order to assess the extent to which cultural competence is present, is maintained, and contributes to desired results with respect to health and health care.  The spectrum of efforts includes assessing organizations, services, and consumer needs and satisfaction. In addition to evaluation and monitoring, organizations and individuals can pursue research activities designed to create and disseminate new knowledge on cultural competence.  From a conceptual perspective, Campinha-Bacote suggests that providers should research and obtain a sound educational foundation about the various world views of different cultures.  Developing a knowledge base helps build cultural awareness which can result in cultural competence.

Exhibit I provides a summary of the ideas related to the domains as found in the key conceptual literature and demonstrates the degree of congruence within the field.  It also portrays to some extent the degree of overlap among the nine domains.  As noted earlier, these nine domains represent the broad spheres or areas in which cultural competence should be evidenced or manifested in culturally competent health care settings. Within these domains, specific topics or subjects further characterize the domains and provide clues to what might be included in a measurement profile. In Section II. C of the report and in Attachment 3, the domains and topic areas are discussed in light of a review of an extensive and wide-ranging set of documents and publications. (See Annotated Bibliography.)


Exhibit I

Comparison of Key Literature (Authors) by the Critical Domains of Cultural Competence



Domains Identified by Lewin

Values and Attitudes

Cultural Sensitivity


Policies and Procedures

Training and Staff Development

Intervention and Treatment Model Features

Facility Characteristics, Capacity and Infrastructure

Family and Community Participation

Monitoring, Evaluation and Research


Cross, et al. View cultural competence as a continuum whereby professional’s views of and attitudes toward other cultures change from being destructive to proficient.  Health care professionals move along this continuum by building a base of cultural knowledge and developing adaptations to diversity.


Agencies or professionals that are culturally blind may believe that they are implementing culturally competent policies and procedures when in actuality their policies may be discriminatory and restrict access to services.


As health care professionals move along the continuum toward cultural proficiency, the care they provide becomes sensitive to cultural differences and the quality of care improves.

Culturally competent agencies or professionals seek to provide services that are accessible to many different cultures.  They have a variety of service model adaptations in order to better meet the needs of minority populations.




Cultural competence is a process whereby providers gradually build cultural awareness, knowledge and skills which result in changing attitudes toward different cultures and, eventually, cultural competence.  Providers can progress toward cultural competence by having encounters with other cultures and drawing on knowledge and skills to adapt to the situation.



Professionals should be trained to collect relevant cultural data when conducting  health histories and physical assessments.

Once all five factors are internalized, providers can experience cultural competence and are able to provide quality care.



It is important to obtain a sound educational foundation concerning the various world views of different cultures.  This involves research and training.


Carballeira’s theory explores the importance of the provider’s attitude toward different cultures and how culturally competent attitudes can improve the quality of patient care.  As providers develop attitudes that are more sensitive to different beliefs and understandings of health and illness, they gain the ability to better assess the patient and provide more appropriate care.



Providers should be trained to use the LIVE and LEARN patient assessment models in order to avoid stereotyping, and provide competent care that leads to changed patient behavior. This patient assessment model helps providers to provide quality care because treatment is planned in a culturally sensitive way based on a cultural assessment such that patients understand treatment and change their behavior to adhere to the treatment.




Davidhizar and Giger


Culturally sensitive encounters include an assessment that helps providers to develop awareness and knowledge of the needs of the particular patient.  Included is an assessment of the patient’s communication style and the verbal and nonverbal cues used by different cultures.  An understanding of these communication cues assists a provider in adequately explaining procedures and instructions.

Health care professionals should be trained in the transcultural assessment model in order to assess the health and well-being of patients from different cultures.  Information collected from this assessment helps to inform the treatment that is given and ultimately improves the quality of care.


The authors stress the importance of understanding the social organization of different cultures.  Health care providers should be sensitive to the family’s role in patient care and encourage participation if appropriate.



Leininger’s assessment requires health care professionals to evaluate acknowledge, and respect cultural differences in world view and social structure.




Leininger suggests that staff be trained in the use of an assessment model to explore the world view and social structure of patients from different cultures.  Health care professionals must develop the skills, knowledge and patience to complete the assessment so that the results can be used to guide patient treatment and interventions.  Leininger sets up a formal framework for how results can be used to inform treatment based on three modalities.

The patients’ response to the facility should be noted and the patient should be made comfortable within the space whenever possible.

The assessment should explore the kinship and social ties of the patients and involve family and/or religious leaders when appropriate.


                                                                                                                                                      Text Box: Sample Topic Areas Addressed by the Critical Domains of Cultural Competence Each of the domains identified contains numerous topic areas that provide a more detailed understanding of the areas in which change can be seen and therefore measured. Some specific topic areas are identified below. (See Attachment 2 for more details) Values and attitudes  acknowledges/ respects different cultures, diversity, mission Cultural sensitivity clinical and non-clinical encounters, non-verbal communication, visual representation Communication  communication styles, interpreter, translated materials, linguistically competent organization, linguistic capacity of the provider, language ability of consumer, provide information, cultural brokering Policies and procedures  choice of health plan network and providers, grievance and conflict resolution, planning and governance, adequate financing, staff hiring/recruitment, incentive systems, policy development Training and staff development  new staff orientation, structured opportunities for ongoing learning, bilingual training, assessment of the knowledge and skills/attitudes of the provider, cultural knowledge, knowledge of community needs, provider preparation Facility characteristics, capacity, and infrastructure - accessible services, physical environment, information system Intervention and treatment model features - diagnosis, care planning, referral, and treatment, quality of care, health benefit design, input into treatment decisions, ethnopharmacology, traditional healers, interdisciplinary teams Family and community participation - family-centered care, community and consumer participation, community outreach Monitoring, evaluation and research  consumer satisfaction, community needs assessment, organizational assessment, evaluation of health plans and providersD-link
C.     Topic areas addressed by the critical domains of cultural competence

Having examined the domains and their grounding in the conceptual literature, this section presents a synthesis of the remaining literature-based evidence supporting each domain.  It highlights specific behaviors, activities, and issues that address the question of cultural competence.

Domain 1:  Values and attitudes

The beliefs and mindsets of organizations, professionals, and consumers influence direct care encounters, shaping the interaction between the consumer and the provider, the provider’s delivery of care, and the way in which consumers perceive care.

These values can manifest themselves at different levels.  At the individual level, the literature discusses the importance of acknowledging and respecting other cultures and the role of culture in health care.  One particular topic area of emphasis is that of provider diversity.  Beyond the individual consumer and provider, the literature highlights the importance of incorporating principles related to cultural competence in organizational missions, visions, and goals.  This represents an area of overlap with the domain of policies and procedures.

Awareness and acceptance of culture and its impact on how care is delivered and received is an essential element in a culturally competent program 8, 9, 10, 11, 12, 13, 14, 15, 16 and applies to both consumers and providers.17  Cultural perceptions influence when a symptom is defined as a health problem and the severity of the problem and whether to seek advice.18

  • Behui, et al. argue that consumers’ unique sets of beliefs about the causation of their change in function and emotional experience influences their determination of who they perceive to be appropriate healers.19

  • Perez-Stable, et al. discuss how the cultural concept of fatalismo (fatalism) in Latino culture may lead some Latinos to be less likely to change behavior to reduce risk or seek care.20

Providers who are aware of cultural beliefs also have more effective communication with consumers,14 highlighting the interconnectedness of the domains of cultural competence.

  • Oomen and Owen examine how to identify and treat Type II diabetes among Latinas and recommend that understanding consumers’ perceptions of diabetes and its treatment would lead to a more culturally sensitive method of diagnoses and treatment.21

  • Crandall, et al. discuss the importance of socially responsible values in the provider workforce by examining attitudes of medical students and how they change.22

Awareness and acceptance can take various forms, from acknowledgment to respect. Identification and recognition of the differences between cultures and how they shape interactions represents a first step towards accommodating and adapting care to respect those differences.23  Carballeira posits that shifts in cultural attitudes of providers and consumers can lead to improved results, and includes elements of that shift in the “LIVE & LEARN” model.  In this model, changes in consumers’ reactions would shift from resistance-accommodation-adaptation while changes in providers’ reactions would progress along a continuum of superiority-incapacity-universality-sensitivity-competence.7  Ultimately, conveying respect during encounters where differences of values exist remains challenging because manifestations of respect depend on culturally-specific norms of interaction.24   Furthermore, the impact of cultural value differences is not limited to race and ethnicity alone but extends to socioeconomic status and power dynamics that differ by race and ethnicity. 25

In addition to awareness, acknowledgment, respect, and acceptance of cultural values and differences, several articles discuss the need to emphasize the value of diversity and other values that promote healthy outcomes for underrepresented groups. 17, 25  Instilling a positive view of diversity differs from, but can co-exist with, targeted recruitment and retention efforts by health care organizations discussed under the policies and procedure domain.  Promoting diversity as a value becomes important as these efforts require time and resources to progress.

At an organizational level, the literature stresses the importance of creating mission and vision statements that articulate an organization’s principles and rationale related to providing culturally competent health care services. These goals and objectives can also manifest themselves in program announcements, policies, and requests for proposals.26, 27

Domain 2:  Cultural sensitivity

Cultural sensitivity generally refers to heightened awareness and complements several other domains, most notably communication.  Lister defines cultural sensitivity as regard for a consumer’s beliefs, values, and practices within a cultural context and awareness of how a provider’s background may influence professional practice.16  Cultural sensitivity also refers to some of the less readily quantifiable aspects of care with regard to culture.  For instance, Hennessy and Friesen discovered that Mexican-Americans were highly concerned with the “caring” with which service was delivered, more than the technical proficiency of the care.28

Non-verbal communication, visual representation, and non-translated culturally-sensitive materials are examples derived from the literature of cultural sensitivity related to communication. 9, 29, 30, 31  Though these topic areas also align with the domain of communication, their evolution from a finely tuned understanding of culture-specific needs and preferences beyond language needs merits their inclusion here.

  • Salimbene discusses how providers and consumers use a “cultural filter” to process a host of information, including facial expressions, body language, and behavior, in provider-consumer interaction.15

  • Wright, et al. study similar issues about non-verbal communication in relation to critical care patients making end-of-life decisions across a range of racial and ethnic groups.  They observe how non-verbal cues are often critical in decision-making and how misunderstandings of these cues can lead to decisions around which little agreement exists.32

  • Yancey and Waldlen describe the success of using Spanish-language videotapes in increasing breast and cervical cancer screening among Latinas and African-American women.  These videotapes included relevant cultural dynamics, varied production elements with entertainment value (e.g., music), information comprehensible to an audience with little formal education, and a minimally didactic presentation.33

  • Guidry, et al. analyze culturally sensitive printed cancer education materials targeted at African Americans, gauge their educational value34 and discuss the need for cultural sensitivity to encompass the culture-specific needs and preferences of those populations for whom English is the primary language of communication.

Domain 3:  Communication

Communication encompasses a wide range of activities that describe the flow and exchange of information among those involved in the provision and receipt of care.  This focuses primarily on interpersonal exchanges between consumers and individual providers and the exchange that occurs between consumers and health care delivery organizations.  The literature discusses a number of concerns regarding communication and how cultural factors may affect the consumer-provider communication,35 including issues related to communication style, language services available to consumers, and language-concordant capacity of providers.

Consumers and providers each possess independent styles of communication.36  There is evidence that having a sufficient number of administrative and provider staff competent in negotiating the communication styles of racial and ethnic groups seeking services can help minimize the need for interpreters and other language services.10  Peer education and testimonials are other mechanisms to communicate across different styles.

  • In studying how to increase breast and cervical cancer screening rates for African-American, Latina, Chinese, and Vietnamese women, Pasick, et al. discuss the importance of peer education and testimonials.  Specifically, they examine different videos and printed brochures employed by a variety of clinics to determine the preferences of specific populations in terms of what information is important for them, how that information should be crafted into a message, and the different media preferences of the various populations.37

  • DiClemente and Wingwood conducted the first randomized controlled trial of community-based HIV sexual risk reduction for economically disadvantaged young adult African American women and found that those who participated in peer education sessions on a variety of topics demonstrated significant improvement in some risk factors relative to their control group counterparts.38

Open communication between the provider, consumer, and the consumer’s family is also critical to gaining understanding between providers and consumers with different communication styles. 

  • Oomen and Owen, in examining how to identify and treat Type II diabetes among Latinas, suggest that providers ask direct questions on follow up visits regarding treatment adherence, barriers to compliance, and possible solutions.21

Language services for those consumers with limited English proficiency or for whom English is not the primary language is of growing importance in making treatment decisions and ensuring appropriate care. 32, 39   These include the provision and appropriate use of interpreters and translated materials, for educational and administrative purposes.  The Culturally and Linguistically Appropriate Services (CLAS) standards stress the importance of interpreters in consumers’ interactions with the health care delivery system.9, 30  The availability of interpreter services that is timely and of high quality is often a concern, and standards for this vary.10, 40  Family and friends are not adequate substitutes for trained interpreters who demonstrate bilingual proficiency and receive training that includes the skills and ethics of interpreting and knowledge in both the terms and concepts relevant to clinical or non-clinical encounters.9

  • Baker, et al. examine the use of interpreters in emergency departments, assessing how often they are used and who usually interprets and studies consumer and provider perceptions of the appropriateness of their use based on respective language capabilities.  They find that regardless of provider competence in the consumer’s language of preference, consumers tend to prefer the use of interpreters, except when the consumer is more comfortable in English than another language.31

  • Randall-David and Pasick, et al. discuss some of the difficulties in selecting an interpreter and stress that providers require training and knowledge in order to work with one effectively. 37, 41

In addition to oral language services, the presence of translated materials helps meet the needs of limited English proficiency consumers. 21, 42  Translated materials can include patient education resources and administrative paper work, including consent forms, and should be translated into primary language of communities served. 9, 43, 27, 37, 44  The translation should minimize the use of medical and professional jargon and be tailored for the appropriate racial and ethnic sub-populations.45  It is critical to test translated materials prior to widespread use.46  Also, direct service providers should gauge the literacy rate of the target population.  High illiteracy would merit more use of interpreter services or other visual representations vis-à-vis printed materials.47

  • The examination of educational interventions to increase cervical cancer screening among non-white elderly by White, et al. reveals that educational interventions increase the awareness and need for routine Pap testing among the elderly but leave consumers’ questions about the most efficient way to obtain this care unanswered.48  These findings highlight how providers need to be aware of their clients’ informational needs and level of comprehension.

Another area widely discussed in the literature relates to language concordance and the linguistic capacity of direct service providers.  The language ability of the consumer is important to consider in order to understand the need for interpreter services9  and can be tracked through patient records.10  Additionally, providers’ reliance on their own language skills is often sub-optimal.  Not being able to rely on the usual linguistic cues may disrupt the degree to which physicians can obtain informed consent and how physicians assess and evaluate symptoms and result in misdiagnosis.49

  • Woloshin, et al. suggest bilingual phrase sheets for staff and consumers as one way to facilitate communication.49

  • Fluency examinations and credentialing represent more rigorous methods to improve the skill of providers who assume interpretation roles.10

Domain 4:  Policies and procedures

Several articles highlight the importance of policy in ensuring that consumers receive appropriate services and helping provider organizations to institutionalize cultural knowledge.25, 43, 50, 51   Policy development can occur in planning and governance, as well as creating  provider incentives and grievance and conflict resolution processes.  Defining the breadth of plan and provider networks and staffing also becomes relevant in a managed care setting.  A precursor of policy development is a process to incorporate cultural competence language on policy statements, including strategic plans and contract requirements.26  Caution should be exercised in policy development as this can serve as a barrier to care.  Agencies or professionals that are “culturally blind” may believe that they are implementing culturally competent policies and procedures when their policies may discriminate against different racial and ethnic groups and restrict access to services.1

Policy changes made at a system level can begin with changes to planning and governance procedures.52  Planning and governance represents a means for organizations to incorporate cultural values and priorities in service delivery and to move from mission to implementation.46

  • The CLAS standards discuss including strategic goals, plans, policies, and procedures as part of a comprehensive management strategy.9

  • Other recommendations in the field for health care delivery organizations include the creation of a cultural competence plan that includes defined steps for its integration at every level of organizational planning and the related policy or procedural changes needed.10

The processes to recruit and retain clinical and non-clinical staff for provider networks also represent policy areas in which health care delivery organizations can choose to act. Several authors view recruitment, retention, and development of staff with cultural knowledge and skills as an element of a culturally competent program.8, 10, 27

  • The CLAS standards recommend developing and implementing a strategy to recruit, retain, and promote a qualified, diverse, and culturally competent administrative, clinical, and support staff that represents the racial, ethnic, and other communities being served.9, 44

  • Several sources suggest that developing specific job descriptions for staff who work with consumers from diverse cultural groups or posting position descriptions and personnel/performance measures that include skill sets related to linguistic competence can also attract personnel with cultural skills and encourage professional development among current staff.27, 53

In the context of managed care, hiring processes may affect network breadth and thus face increased scrutiny. 

  • Rosenbaum, et al. discuss how managed care plans can employ policies that limit the care available to underserved populations and cite areas of concern such as definition of service areas, criteria for membership in provider networks, and segregation of networks for publicly-insured consumers.54

Creating incentives for providers and grievance and conflict resolution processes for consumers is another important policy area that can influence the cultural competence efforts of an organization.  Sanctions and incentives can encourage culturally competent behavior, measuring issues like culture-related complaints and grievance, and should decrease over time as situations change.10  In terms of grievance and conflict resolution, the CLAS standards suggest developing institutional structures and procedures to address cross-cultural ethical and legal conflicts in health care delivery and complaints or grievances by patients and staff about unfair, culturally insensitive, or discriminatory treatment, or difficulty accessing or denial of services.9

Domain 5:  Training and staff development

Training and staff development refer to the ways in which provider organizations can develop cultural competence among health care providers and other staff involved in the provision of care.  Articles discuss the importance of training providers in culturally and linguistically appropriate communication and identify measures and standards to ensure that this type of training as well as training in cultural knowledge occurs.

At its heart, the objective of training is that providers will reach a state of “cultural knowledge” and develop “cultural skill.”  Cultural knowledge means the “student begins to show familiarity with the broad differences, similarities, and inequalities in experience, beliefs, values, and practices among various groupings within society.”55  To reach this stage of familiarity and competence with other cultures the provider must be able to identify and have the ability to understand the cultural worldview and theoretical/ conceptual framework of patients from different cultures.12  For the most part, the necessary methodologies and tools to reach this level of cultural knowledge draw from the fields of clinical ethnography, field study and systems approaches as exhibited in anthropological research.56  This knowledge forms the base of what is known as “cultural skill,” where the provider has developed the skill set to access an individual’s background and formulate a treatment plan that is culturally relevant.12, 56

In designing cultural competence training, federal efforts to understand the standards for culturally and linguistically appropriate services discuss how health providers and health service agencies should require and arrange for ongoing education and training for administrative, clinical and support staff.9  On-going training is integral to progressing towards cultural competence and must be supported by structured opportunities to learn.  These opportunities can be based on a developed framework for cultural diversity educational programs.1, 12, 30, 57  Curricula should be broad based and explore the differences not only among ethnic groups but also among various social groupings defined according to gender, generation, lifestyle, and socioeconomic class.16.

Self-assessment can play a valuable role in the process of working towards cultural competence. Self-assessment tools develop the capacity of the care provider to recognize that one’s own culture and cultural perceptions play a role in the consumer-provider exchange. This in turn should lead to a better understanding of other cultures and the rewards of providing culturally competent care. The training curriculum should assist the caregiver in this process by providing tools for self-assessment.8, 12, 41  The literature presents another method for achieving “self discovery” in training through structured opportunities to work with other cultures and ethnicities.

  • Barton and Brown find that students working with migrant health communities reported deepening respect for cultural minority groups, were able to identify the differences in cultural norms, and recognized the rewards gained in their transcultural experience.57

Domain 6:  Facility characteristics, capacity, and infrastructure

Providers should seek to provide services that are accessible to many different cultures in a location and environment that is accessible and supported by information systems that can track cultural data.1, 12, 43  Accessibility extends to the physical environment in which care is provided and how it is culturally perceived.6

  • Pasick, et al. in their study of the role of culture in health promotion focused on cancer screening for African-American, Latina, Chinese, and Vietnamese women find that many medical care settings and the location of community activities influence the degree to which women obtained care.37

  • Wright, et al. consider the impact of physical space and surroundings in end-of-life decision making and address the how the cultural interpretation of space can affect these decisions.32

Information systems that allow providers to collect and track cultural data are also critical to facilitating health care delivery organizations’ efforts to encourage cultural competence. These data systems should include the capacity to link records by ethnicity in a timely way that allows tracking of patients and protects confidentiality.10

  • Looking at a selection of states, the Texas Department of Health concludes that one lesson in implementing cultural competence is the capacity to gather information and use that information for long-term planning.25

  • The CLAS standards also discuss how health care providers should use a variety of methods to collect and utilize accurate demographic, cultural, epidemiological and clinical outcome data to become informed about ethnic/cultural needs, resources and the assets of the community.9

Domain 7:  Intervention and treatment model features

Interventions and treatment model features range from culturally and linguistically competent evaluation, diagnosis, treatment, and referral services to interactions with traditional healing belief and inclusive decision-making.  Other treatment model features that influence whether consumers and providers interact in a culturally competent manner include care coordination and health benefit design.10, 52  Coordination of services and case management at the community level is an area providers can use to address the needs of diverse populations, particularly to promote continuity of care.53  Many authors suggest that cultural competence is linked to quality of care and enhances it.1, 6, 7, 43

Multiple organizations and research efforts specify the need for culturally and linguistically competent evaluation, diagnosis, treatment, and referral services.15, 40, 58

  • Herrick and Brown discuss the need for planning appropriate culturally competent mental health services for Asian-Americans to ensure that the underuse of mental health services by that population is not inappropriate underuse.59

Full and accurate patient histories are of particular interest and several authors introduce models and protocols for diagnosis that allow providers to take medical histories and conduct an initial assessment in a way that accounts for cultural, sociological, psychological, and biological factors, including the level of the consumer’s acculturation.3, 6, 7, 21, 23, 60

Several authors suggest the establishment of guidelines on a range of clinical issues, such as triage and assessment, care planning, treatment services, and case management.52  These guidelines should avoid stereotyping through superficial master of culture-specific characteristics but should rather build on evidence-based evaluation of cultural information identified through literature reviews and interactions with consumers.61  Some authors suggest that providers have specialized assessment procedures for different racial and ethnic groups and include cultural factors in assessment protocols.10

  • In their study of racial variation in cardiac procedure use and survival, Peterson, et al. find that African-American males treated at Veterans Affairs Medical Centers were less likely than their white counterparts to undergo selected cardiac procedures.  Despite this difference in treatment received, African-American males experienced significantly higher survival rates than the white counterparts.  However, the authors focus on the issue of whether standards of care differ by racial and ethnic group, regardless of outcome.  The authors suggest several reasons for the differences in treatment, including differences in severity and consumer preferences but also differences in how providers may weigh the risk and benefit of invasive procedures differently for African-Americans than for whites.62

  • Todd, et al. study analgesic use in emergency departments and find that ethnicity was the strongest predictor of the lack of use of analgesics.  The authors suggest that providers may encounter difficulty recognizing pain in culturally different patients or that the presence of other decision-makers influence the provider’s decision to administer pain relief.63

  • Oomen and Owen, in looking at why Latinas with Type II diabetes often do not receive appropriate care, suggest that providers identify specific economic, social, familial and religious barriers to treatment adherence and modify treatment regimens accordingly.21

Including providers from multiple disciplines in care teams can facilitate interaction with ethnically diverse communities as well as assist in efforts to reach out to traditional healers.64  Some authors emphasize the importance of cultural concordance between consumers and providers, such that consumers would receive services directly from either competent bicultural/bilingual personnel or personnel representing their own racial and ethnic group.10

  • Goiceochea-Balbona discusses how an interdisciplinary group was able to respond to an HIV crisis in a rural community through bringing together the strengths of the team’s respective disciplines and working with indigenous providers.58

  • The Moy and Bartman study of 1987 NMES data reveals that minority patients were more than four times more likely to receive care from non-white physicians than non-Hispanic white patients and that individuals who received care from non-white physicians were more likely to report worse health.65

Obtaining an understanding of whether consumers are using traditional healers or other non-conventional care is important, particularly in the context of managed care where access to such services is often restricted.8, 21, 31  Some authors encourage providers to reach out to traditional healers and encourage consumers to embrace traditional healing. 10, 30

  • In 1990, almost nine out of ten respondents to a survey conducted by Eisenberg reported seeing a non-conventional provider without the recommendation of their medical provider.66

  • Faculty at the Medical College of Pennsylvania instituted a four-hour session for second year medical students that introduced guidelines for eliciting information from and working with patients with traditional health beliefs and practices, citing the need to understand the prevalence of traditional beliefs and practices in their community.67

  • The Massachusetts Chronic Disease Improvement Network suggests that providers recognize, accommodate, and integrate folk illnesses with biomedical treatments and also recommends working closely with decision-makers to identify, suggest, and explain biomedical alternatives to traditional practices.23

Input into decision-making regarding treatment represents another topic area related to intervention and treatment.  Specifically, the literature’s focus on involving the culturally appropriate decision-makers often concentrates on involving families.31  Establishing agreement on the parameters of care can create an understanding of the diagnoses and securing compliance with treatment regimens.10, 21  This topic also relates to the domain of family and community participation but is included here to illustrate the importance of being inclusive in making treatment decisions.

  • In examining state mental health services, Munoz and Sanchez discuss the importance of involving people from diverse backgrounds in setting provider agendas to encourage providers to gather input from consumers and their families.8

Domain 8:  Family and community participation

Culturally diverse family participation at policy and program levels enhances the ability of providers and health care organizations to serve in a culturally competent manner. 10, 42, 64  Treatment should incorporate familial and community strengths in addition to individual strengths, and appropriate agency resources.10

  • Davidhizar and Giger recognize the unique role of families and the differences in social organization in different cultures.  They stress that providers should be sensitive to the family’s role in patient care and encourage participation if appropriate.6

  • Finley recognizes the role of families in caregiving and discusses the use of support models for families that build upon the strengths of families with diverse racial and ethnic backgrounds.68

  • HRSA’s Maternal and Child Health Bureau suggests steps that health care delivery organizations can take to involve families more intimately in the care process consisting of including extended family in family/provider meetings and conferences and arranging meetings that are convenient and comfortable for families, particularly parents.53

  • Blackhall, et al. summarize a study that examined differences in attitudes regarding informing consumers of a cancer diagnosis among various racial and ethnic groups.  The authors find that although some groups believe the consumer should be aware of the diagnosis, others rely on the family to make the decision as to whether and where to inform the consumer of the diagnosis and treatment option.69

  • In the context of managed care, Starfield, et al. discover that consumers reported on a survey of satisfaction with primary care services better “family-centeredness” when they received services at a facility characterized by high degrees of limitation on physician autonomy or by capitation as compared to receiving services at a facility characterized by a low degrees of limitation on physician autonomy and non-capitated reimbursement.70

Reaching out to cultural groups can enhance providers’ understanding of consumers’ needs while developing their understanding of the location of the group, gaps in service, and barriers to care.42  In assessing ways to improve the linguistic competence of primary care delivery systems, the National Center for Cultural Competence regards support of community outreach initiatives to persons with limited English proficiency as one way to gauge progress.27  Developing relationships with key persons in the community helps providers to learn about the cultural values, beliefs, and practices of the community and provides a vehicle for community members to participate in the health care delivery system.41

  • Goiceochea-Balbona discusses how reaching out to key traditional healers was a critical component in the success of an effort to respond to an HIV crisis in a rural community.58

  • The CLAS standards include recommendations to use formal mechanisms for involving communities and consumers in service delivery design and execution, including planning, policy-making, operations, evaluation, training, and, as appropriate, treatment planning.9

Domain 9: Monitoring, evaluation and research

Monitoring and evaluation are critical to becoming culturally competent because it highlights areas of progress and needed improvement.  This includes organizational assessment and an evaluation of consumer satisfaction and perception and use of services. In addition to evaluation, creating and disseminating new knowledge on cultural competence represents another arena for issues related to cultural competence.

Organizational assessment tools help both individual health practitioners and plan managers to better understand the process of delivering health care to culturally and linguistically diverse communities.55  The literature implies that prior to conducting an organizational assessment, the organization should conduct a community needs assessment to be knowledgeable about the community it serves.25  Additional evaluations should span multiple stakeholders and integrate measures of access, satisfaction, quality and outcome for culturally and linguistically appropriate services into internal audits and performance improvement programs.25

  • The CLAS standards suggest that organizations and providers should prepare an annual report documenting the organizations’ progress with cultural competence, including information on programs, staffing, and resources.9

Analysis of consumer satisfaction and evaluation of services are also integral in providing culturally competent care.40  This feedback is particularly important in managed care organizations and other organizations that monitor provider behavior.  Possible methodologies include focus groups and a patient survey system to measure quality improvement.71  The evaluation of specific services should also include a discussion of how culture affects health care.30, 72

Exhibit II summarizes the references to the domains and sample topic areas by type of literature (e.g., core models and concepts, assessment tools and evaluative models, and program- and condition-specific studies). 

This targeted review of the literature provides evidence for the nine domains of cultural competence and the topic areas within each of them.  In the remainder of the report, these topic areas and domains are discussed with a focus on a measurement framework and potential indicators and measures. 

Exhibit II

Domains and Sample Topic Areas by Type of Literature


Topic Area

Core models and concepts

(24 articles)

Assessment tools and evaluative models

(40 articles)

Program evaluation and condition-specific studies

(62 articles)

Values and attitudes

Acknowledges, respects









Mission, vision




Cultural sensitivity

Non-verbal communication





Visual representation





Culturally sensitive encounters





Communication styles










Translated materials





Linguistically competent organization





Linguistic capacity of provider





Language ability, oral and written, of consumer




Provide information, education





Administration and staff should be able to translate, cultural brokering




Policies and procedures

Choice of health plan network




Choice of providers, provider network




Grievance and conflict resolution




Planning and governance




Adequate financing




Staff hiring, recruitment





Incentive systems




Policy development




Training and professional development

Training and professional development





New staff orientations


Structured opportunities to learn





Bilingual training




Assessment of the knowledge and skills/ attitudes of the provider





Cultural knowledge





Knowledge of community needs




Provider preparation




Facility characteristics, capacity, and infrastructure

Available and accessible services





Physical environment, materials, and resources





Information system



Interventions and treatment model features

Diagnosis, care planning, referral and treatment





Culturally competent services




Cultural competence and quality of care




Culturally competent health benefit design




Culturally competent treatment plan




Culturally competent care




Input into treatment decision and service quality





Use of medicines according to cultural belief, ethnopharmacology





Use of traditional healers, healing methods





Use of interdisciplinary teams



Family and community participation

Family centered care





Community and consumer participation





Family focus, family-oriented, recognition of the uniqueness of the role of the family









Community outreach




Monitoring, evaluation and research

Consumer or member satisfaction and feedback





Community needs assessment





Organizational Assessment




Evaluation of health plans




Evaluation of services




Evaluation of provider





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