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Resources
for Cross Cultural Health Care
and the
U.S. Department of Health and Human Services
Office of Minority Health and the Agency for Healthcare Research and Quality
Developing a Research Agenda for
Cultural Competence in Health Care
Project Overview
As a followup to the development of national standards for
culturally and linguistically appropriate services (CLAS) in health care,
Resources for Cross Cultural Health Care will be facilitating the
development of a health services research agenda on cultural competence
in health care. This project, which will run from November 2000 –
December 2001, will encompass the following tasks:
- Preparing a master literature review of relevant research on cultural
competence interventions, especially as related to health outcomes
- Convening an advisory committee of key researchers, policymakers and
providers to review the literature and make recommendations for a research
agenda to pursue work in this area
- Writing and publishing the research agenda
- Conducting an outreach and dissemination strategy to HHS agencies,
research centers, researchers, funders, purchasers, accreditation bodies,
policymakers, and providers
- Implementing an educational and outreach strategy that will include
development and maintenance of an website and listserv discussion group
to:
- facilitate networking among researchers, policymakers, and providers
- post abstracts of current research and ongoing research projects
- host ongoing feedback on and updating of the research agenda
Background
As policymakers, accreditation bodies, and health care providers are compelled
to deliver health services that are culturally and linguistically appropriate,
questions inevitably arise about the intrinsic and relative value of different
approaches, methods, and programs. These questions may relate to:
- access and outcomes (which interventions increase access for culturally
and linguistically diverse populations to healthcare services and/or
improve their health outcomes?)
- quality and reduction in errors (which interventions increase the
provision of appropriate care to and/or reduce the incidence of medical
errors among diverse populations?)
- cost (which interventions are cost effective, e.g., reduce diagnostic
testing and emergency room use or increase preventive services lowering
future health costs?)
- comparative analyses (which approaches to interventions work best
under what circumstances?)
Common interventions that address cultural and linguistic issues that
are identified in the national CLAS standards include:
- Interpreter services
- Translated materials
- Impact of diverse staff
- Cultural competence training
- Coordination with traditional healers
- Community health workers
- Culturally competence health education
- Family/community member inclusion
- Administrative and organizational accommodations to support cultural
competence
The questions above suggest at least two kinds of investigative work
from which providers and policymakers could benefit. First is the evaluative
work that would look at the elements that distinguish quality interventions
and would compare one approach with another. For example, Hornberger's
work comparing a simultaneous remote interpretation technique with the
more usual consecutive in-person technique is one example. This evaluative
study approach could be applied to different interpreter approaches, cultural
competence training, translation methods, etc.
More challenging, but perhaps more important to those who manage and
pay for services, are the research questions related to quality, effectiveness,
and outcomes. These questions require considerably more complex and resource-intensive
research methodologies.
Contrary to popular perception, research on these issues has been conducted
and is of growing interest to the health services research community.
Much of this work looks at the impact of attempting to improve communication
between clinicians and patients when cultural or linguistic factors are
involved.
However, more work needs to be done to raise awareness about the existing
evidence base for CLAS-related interventions, and to promote continued
research in this area. Advancing a CLAS research agenda involves many
tasks. Funding must be made available for this research. A cadre of interested
researchers needs to be cultivated and networked. Data sets need to be
identified and analyzed.
For example, several institutions with interpreter programs have data
that, in the most cursory analysis, supports the cost-effectiveness of
their programs and a positive impact on some clinical outcomes. However,
these institutions have not had time or resources to investigate these
questions more fully, or have not been able to find researchers to do
this for them.
Another important task, especially given the limited resources available
in this field for research on CLAS services, is better information-sharing
about research projects to promote collaboration and avoid duplication
of effort. For example, at this time there are at least three projects
looking at the cost-effectiveness of interpreter services, and two surveys
being developed to quantify the linguistic and culturally appropriate
practices of managed care organizations.
Developing the CLAS Research Agenda
In July 1998, the CLAS Standards Project Advisory Committee identified
a number of key questions on CLAS research that suggest general issues
for further exploration. The questions address definitional, methodological,
and research infrastructure issues, and include:
- What is CLAS, and what definitions can we agree on? Is it necessary
to agree on a single, universal definition?
- When doing a literature search, what key words will yield relevant
research?
- What research studies exist, and what additional research questions
need to be answered?
- What are the domains of measurement for CLAS interventions?
- Where is the data and how hard is it to get?
- What methods should be used for analysis, and what are some of the
problems of relating CLAS interventions to standard outcomes?
- Who should conduct CLAS research, and how should they be involved
and networked with each other?
- What funding is available for CLAS research and how can interest in
this area be nurtured?
- What are publication concerns around CLAS research?
- How do we translate the research agenda and findings for stakeholders,
including providers, policymakers, and other researchers?
These questions have been addressed by the national Research Advisory
Committee in its April 2001 meeting and form the basis for the final CLAS
research report, which will be available in early 2002.
Individuals interested in providing input into the development of the
research agenda and discussion issues related to conducting research on
CLAS are invited to review our project input pages.
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