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Organizational Supports for Cultural Competence
Literature Review Abstracts

The concept of "culturally competent" health care combines the tenets of patient-centered care with an understanding of how patients' social and cultural influences can affect their interactions with the health care system and, ultimately, their health. There is now a growing recognition that cultural competence is an essential component of effective health care. This project will identify promising strategies to address culturally based barriers to care, helping the health system respond better to the needs of minority patients.

Del Castillo, Ramon R.
Effective Management Strategies When Incorporating Curanderismo into A Mainstream Mental Health System. (folk healing).
Dissertation Abstracts International: Section B: the Sciences & Engineering. Vol 60(4-B), Oct 1999, 1524.

As America approaches the year 2000 and beyond, coupled with the challenges of a growing and diverse population, public administrators will be asked to do more with less. The Congress in American government will continue to grapple with the question of health and mental health care for all of its citizens; therefore, it is useful to include all relevant modalities of health and mental health care in the debate. Additionally, in order to insure effectiveness and prudent expenditure of the public's dollars, as health and mental health care providers attempt to incorporate alternative methods of treatment into its health and mental health care systems, associated management strategies that accompany these innovations should also be analyzed. There is a paucity of literature regarding management problems and strategies associated with incorporating what is considered to be a non-traditional form of mental health treatment into mainstream systems. This research is exploratory in nature, utilizing the topical life history approach with both curanderas/os (indigenous healers) and public administrators and managers. These public servants were involved in the implementation of curanderismo, defined as the practice of spiritual folk medicine, generally used in Indian and Mexican-American communities as it was implemented in a publicly funded mental health system. This dissertation asks the question what management strategies are effective when incorporating curanderismo into a publicly funded mental health system. The actual research demonstrates those strategies used by Southwest Denver Community Mental Health, a publicly funded mental health center, now consolidated under the Mental Health Corporation of Denver, as curanderismo was first introduced into the system, followed by a process of institutionalization. Analyzing the findings of this research through the eyes of organizational innovation, this research outlines those management strategies that were effectively implemented that eventually resulted in the institutionalization of curanderismo into the system, both as a treatment modality and as educational strategy. The findings of this research demonstrate that the incorporation of curanderismo into a mainstream mental health system was successfully accomplished. Some of the management strategies that were learned include the building of a solid infrastructure to support alternative mental health programming, the demonstration of effective leadership, a strong minority voice, the introduction of intermediaries who play key roles in the process of institutionalization and cultural competency.

Frayne, S. M., MD, MPH., R. B. Burns, MD, MPH., et al.
The Exclusion of Non-English-speaking Persons from Research.
Journal of General Internal Medicine 1996(11): 39-43. 1996

Objective: we sought to determine how often non English-speaking (NES) persons are excluded from medical research.

Design: self-administered survey. Participants: we identified all original investigations on provider-patient relations published in major U.S. journals from 1989 through 1991, whose methodology is involved in direct interaction between researcher and subject (N = 216). Each study's corresponding author was surveyed; 81% responded.

Measurements and Main Results: of the 172 respondents, 22% included NES persons; among these includers,16% had not considered the issue during the study design process, and 32% thought including the NES had affected their study results. Among the 40% who were excluded the NES (excluders), the most common reason was not having thought of the issue (51%), followed by translation issues and recruitment of bilingual staff. The remaining 35% (others) indicated that there were no NES persons in their study areas.

Conclusions: Many persons are commonly excluded from provider-patient communication studies appearing in influential journals, potential you limiting the generalizability of study findings. The cause they are often excluded through oversight, heightened awareness among researchers and granting institutions, along with the development of valid instruments invaried languages, may increase representation of the non-English-speaking subjects in research.

Garcia-Caban, IA
Improving Quality of Care for Racial and Ethnic Minority Populations: A Study of Cultural Competence in Acute Care Hospitals

Despite an abundance of first rate medical institutions in this country there continues to be significant problems in access and health services delivery for racial and ethnic minority populations as evidenced through their dramatically shorter lifespans, higher morbidity rates and continued inaccessibility of quality health care. The rapidly changing demographics along with persistent disparities in health status have prompted initiatives among national, federal and state health organizations to address cultural competence standards and measures. Problems of system under-utilization have been linked to the lack of adequate system responsiveness in addressing the cultural expectations and rules for appropriate delivery of services. The consequence of discounting these cultural expectations/rules for services may have serious consequences for reducing health disparities among racial and ethnic minority groups and improving access to quality care in an increasing multicultural society.

Research Goal and Objectives: The goal of the proposed exploratory study is to examine how the Massachusetts acute care hospital industry is undertaking structural and process improvements to organize and deliver health care services that address quality, access to care, and effectiveness for racial and ethnic minority consumer groups. The research questions seek to investigate:

1. At what structural levels are acute hospitals more (or least) likely to adapt quality improvement efforts to develop competence in delivering care to racial and ethnic minority groups?;
2. In what manner do acute care hospitals with more vs. lesser structural adaptation describe implementing service processes to improve delivery effectiveness for these minority groups?; and
3. In acute care hospital settings which have more vs. lesser organization-wide activity: who are the cultural brokers contributing to organizational response for cultural competence efforts, what are their roles in advancing policies and practice that leads to developing culturally competent systems of care, and what do they identify as important to fostering system change in service practices?

Sample Frame: The sample frame for this study are twofold: a) all acute care hospitals contracted with the Massachusetts Medicaid program; and b) cultural brokers/key informants from select hospital settings responsible for reporting to Medicaid. Recruitment of cultural brokers is based on non-probability sampling procedures using a purposive sampling method and will include approximately 50 informants from a subset of eight acute hospital facilities. Ethnographic sites were selected based on the following criteria: four hospitals each that report low vs. high cultural competence activity; report serving at least 5 percent of total racial and ethnic minority patient mix; and have primary cultural brokers/informants that have been with the hospital facility at least 6 months to one year.

Data Collection Methods and Sources: Several sources provided the data for this study:

1. hospital quality measures gathered through the Massachusetts Medicaid acute hospital contract process for rate years 1997-1999;
2. hospital demographic data from the Massachusetts Rate Setting Commission for respective rate years; and
3. ethnographic interviews with cultural brokers/informants in a subset of acute hospitals.

The Medicaid contract gathered quality measures data on structure, process and outcomes. Select cultural competence measures included a 28 item cultural competence organizational self-assessment (CCOSA) checklist; provider-patient multicultural mix, interpreter service standards, stratified clinical outcome/process indicators, and patient satisfaction survey data. Ethnographic procedures involved semi-structured interviews with key cultural brokers/informants and cultural competence organizational workgroups. Group participants completed a 10 item questionnaire on participant demographic profile.

Data Analysis Methods: Analysis combined quantitative and qualitative methods to answer the research questions. Quantitative analysis is used to describe industry trends and patterns in patterns in structural and service process adaptations aimed at building competence. Item scale reliability was performed on the four CCOSA checklist subscales (governance policy, administration, service delivery, customer relations) using cronbach’s alpha test to examine its appropriateness in measuring a culturally competent system of care. Concurrent validity of CCOSA was performed using Pearson correlation test. Descriptive statistics on means and distribution of CCOSA individual and subscale means were also performed. ANOVA’s, t-tests, and chi squares, are used to compare groups by hospital type, size and region along the four CCOSA subscale scores. Qualitative analysis employed content analytic techniques using a standardized coding tool and hermeneutic methods to assess organizational documents. Cross-case thematic analysis methods are used on ethnography data to explore the factors that might explain differences in system response to improve access to quality care for racial and ethnic consumer groups. The proposed study has both theoretical and practical policy relevance as it will provide a framework for health care organizations, regulatory bodies and purchasers of care to identify, measure and monitor quality indicators that lead to improved performance and access to quality care for racial and ethnic minority consumers.

Giacomelli J.
A Review of Health Interpreter Services in A Rural Community: A Total Quality Management Approach.
Australian Journal of Rural Health. 5(3):158-64, 1997 Aug.

The current focus in health care is on total quality management (TQM), a process that involves ongoing quality improvement and benefits both internal and external customers. In order to comply with the values of TQM, the Griffith Murrumbidgee Health Service set up a team to review the use of interpreters in a healthcare setting. Staff from a number of wards/units filled out a survey sheet regarding interpreter services for each patient/client presenting for service during a 1-month period. The results showed that (i) there was a marked tendency by staff to use non-accredited interpreters; and (ii) staff who used non-accredited interpreters tended to inappropriately assess patient/client interpreting needs and to be unfamiliar with the Health Care Interpreter Policy. The TQM team subsequently devised several strategies for change.

Glover SH. Shi L. Samuels ME.
African-American Administrators in Community/Migrant Health Centers.
Journal of Health Care for the Poor & Underserved. 8(2):153-69, 1997 May.

Community and migrant health centers (CHC/MHCs) play a secondary role as avenues for the development of minority and women health care professionals, groups traditionally underrepresented in administrative and managerial positions within the health care system. This paper focuses on the role of CHC/MHCs in eliminating the barriers that typically limit the professional advancement of these groups. In a survey of both rural and urban CHC/MHC administrators, it was found that CHC/MHCs have higher percentages of minorities in top management positions than general management but do not necessarily reflect the minority composition of those being served. Of the CHC/MHC administrators, 20 percent were African American, less than the population served (31 percent) but greater than the percentage of African Americans in the general U.S. population (12 percent). This suggests that CHC/MHCs have partially met the original goal of upward mobility and that there is room for improvement.

James CE.
Cultural Interpretation Services Within A Multicultural Context: An Exploration of The Problematic and Ethical Issues Facing Social Service Institutions.
Canadian Journal of Community Mental Health, 17(2):51-66, 1998 Fall. (47 ref)

This paper explores the challenges for social service agencies which offer cultural interpretation services in their bid to meet die needs of service seekers and recipients from linguistic minorities. The author argues that cultural interpretation is provided by institutions that have done little more than add a service for clients from cultural minorities, while leaving intact their service structures-structures that have historically viewed language and "cultural differences" as problems. This orientation will need to change if these services are to be accessible and equitable for Canadians from linguistic and ethnic minorities. While cultural interpreters remain critical to service delivery, they need to work within institutions where service providers and administrators understand language as a cultural, social, and political instrument through which individuals articulate their identities, realities, and understandings of their cultural contexts and service needs. This paper concludes by identifying some of the ethical dilemmas and questions that attend the needed institutional changes. (47 ref)

Johnson AE. Baboila GV.
Integrating Culture and Healing. Meeting The Health Care Needs of A Multicultural Community.
Minnesota Medicine. 79(5):41-5, 1996 May.

Delivering health care to culturally diverse patients is fast becoming an integral part of patient care-a change driven by shifting demographics in Minnesota and especially in the Twin Cities metro area. At United Hospital and Children's Health Care-St. Paul, ethnographic research is being used to create cross-cultural health care information systems that address the needs of providers and patients. These include an easy-to-use computer-based information system, brown bag seminars, and cross-cultural skills training. This article discusses that hospitals' efforts to identify provider needs, collect cultural information, and disseminate that information in a manner that supports quality and cost-effective health care delivery.

Kaufert, Joseph M; Koolage, William W.
Role Conflict Among "Culture Brokers": The Experience of Native Canadian Medical Interpreters.
Social Science & Medicine, 1984, 18, 3, 283-286

An examination of role conflicts among Cree & Saulteau language speaking interpreters working in 2 urban hospitals providing tertiary medical care services to native Canadians from remote northern communities, based on 18 months of participant observation & analysis of 4,000 videotaped clinical consultations. An inventory of roles & situational contexts characterizing the interpreter's work in this setting is developed. Sources of role conflict were associated with cross-pressures in their work as language interpreters, culture brokers, & patient advocates. 10 References. Modified HA (Copyright 1985, Sociological Abstracts, Inc., all rights reserved.)

Kaufert JM. Putsch RW. Lavallee M.
Experience of Aboriginal Health Interpreters in Mediation of Conflicting Values in End-Of-Life Decision Making.
International Journal of Circumpolar Health. 57 Suppl 1:43-8, 1998.

This paper examines the experience of Aboriginal medical interpreters working with terminally ill patients, family members, and care providers, and serving as mediators when cultural values and decision frameworks are in conflict. The discussion is based on a qualitative analysis of interaction in 12 patient encounters which were observed and for which transcripts were made of the discourse and interaction. Each case involved intervention by a professional interpreter. Interaction involved the signing of advance directives or other consent agreements in situations in which Aboriginal patients were terminally ill. Analysis will focus on the cultural dimension of value conflict situations, particularly in relation to issues of individual autonomy and biomedical emphasis on truth-telling in the communication of terminal prognosis.

Koseki LK.
A Study of Utilization and Satisfaction: Implications for Cultural Concepts and Design in Aging Services.
Journal of Aging & Social Policy, 8(1):59-75, 1996. (11 ref)

This article describes the utilization and satisfaction patterns of Native Hawaiian elders with the Ke Ola Pono No Na Kupuna ("Good Health and Living for the Elderly") project funded under Title VI-B of the Older Americans Act. Data were collected through a self-administered questionnaire. Its unique, one of a kind, culturally specific program, which includes traditional Native Hawaiian meals, has a number of implications for policy considerations in designing aging programs that can serve ethnic minority aged more effectively. Changes in current federal policy that would enable federally mandated aspects of programs to provide for greater flexibility in providing culturally relevant programs and services for ethnic minorities would help to surmount some of the current problems and barriers to service delivery and utilization by ethnic minority groups. Allowing for greater involvement of ethnic minorities in program design will help to assure culturally relevant and appropriate activities and services and may increase the likelihood of success due to a sense of personal ownership and self-responsibility on the part of those involved. (11 ref)

Lavizzo-Mourey R. Mackenzie ER.
Cultural Competence: Essential Measurements of Quality for Managed Care Organizations [editorial].
Annals of Internal Medicine. 124(10):919-21, 1996 May 15.

Myrick, Roger.
In Search of Cultural Sensitivity and Inclusiveness: Communication Strategies Sued in Rural HIV Prevention Campaigns Designed for African-Americans.
Health Communication. Vol 10(1), 1998, 65-85.

Recently, rates of HIV and AIDS have been rapidly and disproportionately increasing among minority communities in the rural South. Culturally specific health communication about HIV and inclusion of minority voices in the administration and implementation of HIV programs have been found to be the most effective methods for prevention. The purpose of this discussion is to examine these health communication strategies in HIV prevention programs designed for African American communities in rural Alabama. Effective, culturally sensitive, and inclusive prevention efforts documented in health communication literature are identified, and the use of these efforts through a case study of rural Alabama's minority-focused HIV prevention programs is examined. The research reveals that, although the state is making use of culturally tailored communication strategies, educators continue to encounter problems connecting with and involving target populations. Reasons for these problems and recommendations for changes are discussed.

Ratliff SS.
Waterfalls and Geysers: The Development of Diversity Awareness at Children's Hospital.
Journal of Nursing Care Quality, 13(3):36-46, 1999 Feb. (1 ref)

The development of diversity awareness at Children's Hospital in Columbus, Ohio, has been a work in progress since the early 1980s. The interface of administration and individual initiatives ("waterfalls" and "geysers") has resulted in projects ranging from major international exchange programs to noontime Spanish language classes. This article recounts the journey from a parochial focus to a consciousness of multiculturalism in virtually all aspects of hospital interaction. Copyright (c) 1999 by Aspen Publishers, Inc. (1 ref)

Resick LK. Taylor CA. Carroll TL. D'Antonio JA. de Chesnay M.
Establishing a Nurse-Managed Wellness Clinic in A Predominantly Older African-American Inner-City High Rrise: An Advanced Practice Nursing Project.
Nursing Administration Quarterly. 21(4):47-54, 1997 Summer.

With funding from a U.S. Department of Housing and Urban Development contract awarded to a private university, advanced practice nurse faculty established a nurse-managed wellness clinic in an apartment building populated by predominantly African American older people. Ethnographic methods were used to ensure culturally competent care. The clinic provided nursing, pharmacy, and health sciences faculty and students with community-focused clinical experiences as interdisciplinary team members.

Richardson LD.
Patients' Rights and Professional Responsibilities: The Moral Case for Cultural Competence.
Mount Sinai Journal of Medicine. 66(4):267-70, 1999 Sep.

A right to health care can be derived from basic ethical principles. The empirical evidence revealing significant racial inequities in health status, access to health services, quality of care received and outcomes of health services is reviewed. The need for health care providers to acquire cultural competence in order to fulfill their professional responsibilities is discussed; the insight, knowledge and discipline required to function effectively in the context of cultural differences are described. The broader implications of cultural competence for institutional and public policy, research and professional education are outlined.

Salimbene S.
Cultural Competence: A Priority for Performance Improvement Action.
Journal of Nursing Care Quality, 13(3):23-35, 1999 Feb. (6 ref)
J NURS CARE QUAL. 13(3):23-35, 1999 Feb. (6 ref)

An increase in diversity that has been accompanied by a sharp decrease in white Caucasian "mainstream" culture has made cultural competence a priority in nursing performance improvement. Each culturally diverse group defines health and illness differently. Most have a long and well-established tradition of folk health beliefs and practices, which strongly impact members' reactions to American standards of care--an influence on both patient satisfaction and treatment compliance. This article describes the culture--health care relationship and lists 10 indicators for measuring cultural competency. It presents a practical, systemwide model for the improvement of nursing care quality through enhanced cultural competency and lists resources, which can be used to both support and improve cultural competency throughout an integrated health care system.

Sherer JL.
Crossing Cultures: Hospitals Begin Breaking Down The Barriers to Care.
Hospitals, 67(10):29-31, 1993 May 20.

Simpson E. Gawron T. Mull D. Walker AP.
A Spanish-Language Prenatal Family Health Evaluation Questionnaire: Construction and Pilot Implementation.
Journal of Genetic Counseling, 3(1):39-62, 1994 Mar. (19 ref)

The Family Planning Council of America has constructed and implemented a genetic history questionnaire, the Family Health Evaluation, to elicit risk factors, to increase clients' knowledge about reproductive choices, and to improve access to genetic services. The objective of the present study was to improve access to genetic services. The objective of the present study was to develop and implement a Spanish-language version of the Family Health Evaluation for data collection and risk assessment. The content of the Family Health Evaluation was modified to more clearly reflect the risks, exposures, and medical needs of an Hispanic, largely Mexican-American, population. In the present study, the questionnaire was administered to women presenting for prenatal care. The data collected in this pilot study indicate that the questionnaire is effective in identifying individuals and families who would benefit from receiving additional information about a medical condition in their families, from genetic counseling or from a referral for high-resolution ultrasound or other diagnostic procedures. (19 ref)

Stanton B. Black M. Feigelman S. Ricardo I. Galbraith J. Li X. Kaljee L. Keane V. Nesbitt R.
Development of ACulturally, Theoretically and Developmentally Based Survey Instrument for Assessing Risk Behaviors Among African-American Early Adolescents Living in Urban Low-Income Neighborhoods.
AIDS Education & Prevention. 7(2):160-77, 1995 Apr.

The creation of developmentally and culturally appropriate data-gathering instruments is necessary as health researchers and interventionists expand their investigations to community-based minority adolescent populations. The creation of such instruments is a complex process, requiring the integration of multiple data-gathering and analytic approaches. Recent efforts have delineated several issues to be considered in survey design for minority populations: community collaboration; problem conceptualization; application of the presumed model of behavioral change; and dialect and format of delivery. This paper describes the process of creating a culturally and developmentally appropriate, theoretically grounded instrument for use in monitoring the impact of an AIDS educational intervention on the behavior and health outcomes of urban African-American pre-adolescents and early adolescents. Three phases of research were involved: preliminary (and ongoing) ethnographic research including extensive participant observation, as well as, focus group and individual interviews with 65 youths; construction and testing of the preliminary instrument involving two waves of pilot testing (N1 = 57; N2 = 45); and, finalization of the instrument including reliability testing and assessment of tool constructs and selection of the mode of delivery (involving 2 additional waves of pilot testing (N3 = 91; N4 = 351). The essential role played by the community in all phases of instrument development is underscored.

Stolk Y. Ziguras S. Saunders T. Garlick R. Stuart G. Coffey G.
Lowering The Language Barrier in An Acute Psychiatric Setting.
Australian & New Zealand Journal of Psychiatry. 32(3):434-40, 1998 Jun.

Objectives: The aim of this paper is to investigate the effectiveness of a training and policy strategy to improve communication opportunities in an acute inpatient unit for patients of non-English-speaking background (NESB) with low English proficiency.

Method: A pre- and post-intervention design involved: (i) a survey of the multilingual skills of 80 clinical staff; (ii) recording of patients' ethnic background and proficiency; (iii) pre- and post-intervention data collection of the main outcome measure (communications with patients in a language other than English [LOTE]); and (iv) staff training, and active encouragement, in interpreter use. English proficiency was assessed using the population census proficiency question.

Results: Of 257 admissions, 33% were of NESB and 19% preferred to speak a LOTE. The staff survey yielded a 49% return rate and showed that, of 11 LOTEs spoken by patients, seven were also spoken by 17 of the staff. Twenty-nine percent of staff were not clinically proficient in these languages. Compared to the NESB population, a higher proportion of NESB patients rated low on proficiency. Following the intervention, interpreter bookings and booking duration increased significantly.

Conclusions: A standard training package and a policy promoting interpreter use improved communication opportunities in an acute setting where language needs are typically poorly met. Failure to ensure effective communicate raises risks of misdiagnosis and inappropriate treatment. By measuring patients' proficiency directly, the present study identified a higher level of need for interpreter services than estimated by past reports.

Sublette, Elizabeth; Trappler, Brian.
Long Island Jewish Medical Ctr, Hillside Hosp, Dept of Psychiatry, NY, US.
Cultural Sensitivity Training in Mental Health: Treatment of Orthodox Jewish Psychiatric Inpatients.
International Journal of Social Psychiatry. Vol 46(2), Sum , England: Avenue Publishing Co. 2000, 122-134.

Examined cultural and religious issues arising in the treatment of 15 Orthodox Jewish inpatients (mean age 36.7 yrs) with major psychiatric disorders at a Brooklyn, New York hospital during the period 1994-1998. Cross-cultural therapeutic goals included integrating patients into the milieu environment and allowing legitimate religious practices while setting limits on maladaptive ritual. To minimize patient alienation, ward policies were modified. Cultural sensitivity training among staff included accommodating customs regarding rules of modesty, sexuality, loyalty, and honor. Cultural and religious factors distinctly affected presentation, therapeutic interventions, and transference-countertransference reactions. Religion was used by patients and families as a means of defense, rationalization, or power-brokering.

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