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Developing a Research Agenda for Cultural Competence in Health Care:
Racial, Ehnic, and Linguistic Concordance
Draft research agenda--version 1.0

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  

We invite public input on our draft research agendas. Please read the following document and send your comments to rcchc@aol.com. We are especially looking for recommendations for additional research questions and methodological/policy considerations. We are also seeking additional bibliographic references for the literature review abstracts. Comments received by December 10 will be incorporated into the final report–comments will also be posted online.

Definition

Racial, ethnic, and linguistic concordance refers to the process of matching any or all such characteristics between patients/consumers and clinicians. The underlying assumption behind this process is that the sharing of such characteristics will lead to a higher degree of comfort, communication and empathy between participants in a clinical encounter by reducing differences in cultural and linguistic backgrounds, and thus have a positive impact on outcomes.

Some literature suggests that concordance can be applied beyond the clinical encounter to encompass a combination of characteristic matches that can be incorporated in a race/ethnic/language-specific clinic site or program. It is theorized that successful delivery of health services to different racial and ethnic populations requires an understanding of the cultural milieu of each distinct community, as well as the trust of communities and individual patients. This understanding and trust can be obtained by securing staffing patterns that mirror the targeted service population. Incorporating a team that reflects the community dynamics can instill this assurance and assist in the development of culturally appropriate and acceptable care essential to a successful program.  

Synthesis Of Findings From Current Literature

• Patients from different multicultural groups may prefer to seek care from providers of their own race, ethnicity, or language group
• Concordance appeared to have a positive impact on appropriate service utilization, treatment participation, receipt of some services.
• Impact on satisfaction was inconclusive.
• Effect of positive outcomes in utilization did not translate into improvements in health outcomes.
• Research was conducted with Asian, Hispanic, and Black concordant encounters–findings should be considered specific to the groups studied, and not generalizable across ethnic groups.

Literature Search Terms

Demographic matching, cultural parity, culturally diverse staff, cultural responsiveness, staff diversity, ethnic parity, workforce diversity, cultural matching, minority recruitment, provider retention, minority providers, medical/nursing school admissions, racial concordance, ethnic concordance, racial matching, ethnic matching, multicultural professionals, intercultural education/training, professional diversity

Key Research Questions

A. Research that attempts to further define/understand the intervention itself

What can we learn from concordant encounters about patient/consumer needs and desires in a clinical encounter? This question aims to further define patient/consumer perceptions about what specifically is important about concordance in medical encounters: is it race, ethnicity, gender, SES, culture, language, communication styles? What can we learn from concordant encounters about factors that could be emulated in non-concordant encounters? What factors are not definable or replicable? Are there factors that are common among racial/ethnic/language groups, or does each cultural group respond to unique factors?

B. Research that examines specific outcomes related to the intervention  

Does concordance affect patient/consumer: comprehension, satisfaction, appropriate utilization of services, adherence to treatment, perceived health status and/or quality of life measures? Do positive outcomes in any of these areas correlate to medical/condition/health status improvements?

Does concordance have an effect on clinician behavior/perceptions? Measures could include time spent with patients/consumers, number of treatment options discussed, level of interaction/negotiation of treatment options, clinician perceptions of effectiveness of their efforts, and patient adherence to treatment recommendations.

Do findings related to outcomes in concordant encounters vary by different racial, ethnic or linguistic groups? Would Bosnian refugees in concordant encounters show more positive outcomes than third generation, English-speaking Latinos? Is there a variable impact related to the effects of: length of time in this country, acculturation, education level, religious and gender matching, experience of war/trauma/torture?

How do the outcomes of concordant encounters compare with those with clinicians who have received cultural competence training? What factors and behaviors can be found in both types of encounters and which are not replicable? How important is a choice of a concordant provider to patients/consumers? Does the lack of choice have an impact on overall health service utilization or satisfaction with a health care system or plan? Does a lack of concordant support staff affect perceptions of a system or plan, service utilization, or satisfaction? [Cross-reference to organizational support category]

What are the broader implications of concordance outside of the medical encounter, particularly the systemic implications? Does concordance achieved through a diverse staff improve the service delivery efforts targeting multicultural communities? Does the overall level of staff awareness and sensitivity to cultural issues improve? What mechanisms exist in the organization to facilitate communication and learning among staff and across the organization? Do negative issues arise among staff from efforts to diversify a staff to achieve concordance?

Research And Policy Considerations For Further Work In This Area

The following two articles describe the methodological complexities that need to be considered when measuring the impact of racial and ethnic concordance in health services. We are reviewing the full text of these articles to incorporate relevant points into this section.

Sawyer L, Regev H, Proctor S, Nelson M, Messias D, Barnes D, Meleis AI
Matching Verses Cultural Competence In Research: Methodological Considerations.
[59 refs] Research in Nursing and Health, 18(6): 557-67, 1995 Dec.

Conceptual issues for cultural matching in research projects include:

1. what to match (ethnicity, geographic area and/or residence, language, social class, social values, gender, etc.),
2. when to match (during question development), data collection, data analysis, dissemination of findings,
3. and feasibility of matching (availability and costs).

Essential components in the conduct of culturally competent research include cultural knowledge, cultural sensitivity, and collaboration. Culturally competent knowledge will not be developed and expanded without methods and research processes that are more congruent with population diversity. We have argued that the complexity inherent in matching hinders, rather than promotes, the pursuit of cultural diversity in research. We further argued that matching may be one possible strategy but that it, in itself, does not ensure cultural competence in the research process.

Flaskerud JH.
Matching Client And Therapist Ethnicity, Language, And Gender: A Review Of Research.
[Review] [39 refs] Issues in Mental Health Nursing. 11(4):321-36, 1990.

The purpose of this article is to examine whether therapy process and outcome are influenced by a client-therapist ethnicity, language, or gender match. A review of research in this area does not demonstrate support for a client-therapist match on any of these variables. The methodological problems and unresolved conceptual issues involved in this research may limit the findings. The ethical and political context of the research and the implications for mental health nursing are explored. [References: 39]

The advisory committee expressed a great deal of dissent around the applications of provider-patient concordance. The majority of participants expressed uncertainty about the policy implications of concordance and where it would ultimately lead.

Current research suggests that patients perceive and experience positive benefits from concordant encounters, suggesting an adequate rationale for providers to pursue this strategy as an organizational goal when reasonably achievable. The literature particularly appears to support the benefits of language-concordant encounters, although further research should examine the differential impact of concordant encounters with those using interpreters.

Aside from outcomes considerations, further research on the dynamics of concordant encounters and ethnic-specific clinics and programs could be very helpful in improving non-concordant encounters through program design and staff training. The research reviewed did not examine the benefits to an organization of having a diverse staff. Is it simply a "wallpaper" effect–the visual evidence of diversity is reassuring to patients, or do diverse staff make a quantifiable contribution to the understanding and ability of all staff to address the cultural issues presented by clients and the community?

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