1.7 Cross
Cultural Health Programs & Initiatives
Like many cultural competence training approaches,
cross cultural health programs and initiatives often fall into one of
two categories: programs that focus on specific population groups and/or
health conditions, and programs that address overall organizational cultural
competence. Over the years, efforts to reduce the disparities in health
status between Caucasian and "minority" groups have led to millions of
dollars spent on targeted interventions for particular ethnic groups or
communities. Ideally, these programs at their heart are culturally appropriate
for the intended participants, and are usually developed by or in collaboration
with representatives of the target population. Many model programs, practices,
and approaches have been developed, continue to be funded and should be
funded, although comprehensive evaluations that encompass the breadth
of potential audiences, approaches, and intended outcomes typically has
not been undertaken. Similarly, there have not been any systematic attempts
to survey across interventions developed for specific ethnic groups to
synthesize what common practices or techniques may facilitate replication
or adaptation from one group or setting to another.
Increasingly, programs are being developed to address
overall organizational cultural competence when the target audience may
be quite ethnically diverse. This is the reality faced by the vast majority
of large providers, and it is primarily these types of programs that the
following discussion will address.
1.7.1 Organizational Competence
Again, the members of AAPCHO offer an excellent
collection of models of organizational competence, and their report (Appendix
2) highlights many of the organizational components that could be applied
to other providers. Other non-community health center models of organizational
cultural competence include:
New York Downtown Hospital: this hospital revived
itself financially by a CEO-driven commitment to concentrate on and tailor
services to the New York Chinese community. Its approach is comprehensive,
including all aspects of patient care, community outreach, education,
and marketing, and so successful that Chinese clients travel to use its
services from all over the Northeast.
Kaiser Permanente: this MCO sponsors a plan-wide
Diversity Council to discuss and share ideas about improving access and
services for diverse populations. Each regional unit is responsible its
own activities, although many initiatives have come from the Southern
California region, and include provider education workshops, resources
manuals, and promotion of culturally competent services and policies with
marketing and administration (see Appendix 9).
Harvard Pilgrim Health Care: this MCO has an
office and Vice President for Diversity and has systematically analyzed
all organizational units for improvement with respect to culturally appropriate
services and policies. They began with interpreter training and services
implementation, have developed a staff cultural competence training program,
and have a Diversity Journal that summarizes and promotes diversity practices
within the plan.
Metropolitan Health Plan: this Minnesota public
HMO goes beyond a traditionally anthropological definition of cultural
competence to include socioeconomic and educational concerns like telephone
access, transportation, child care, and literacy levels. In testament
to the necessary management support for culturally competent activities,
their administrative and marketing leadership are vocal in their appreciation
of the relationship between these activities and increased member satisfaction
and market share.
In general, it is easier to develop organizational
policies and programs of cultural competence for specific ethnic groups
(ie. AAPCHO, New York Downtown Hospital). Similarly, individual programs
targeted at specific populations (ie., Latinos), subpopulations (women)
or disease conditions (diabetes) are easier to implement than overall
organizational cultural competence. It is also more challenging to achieve
truly multiethnic competence. It would be difficult to characterize
any of the multiethnic models listed above as completely culturally competent.
Indeed, many organizations tout their achievement in cultural competence
by citing individual programs when the organization as a whole may still
be unfriendly to diversity at many points. Because the variety of points
of contact and organizational units that require attention can be so large,
true organizational cultural competence is impossible without commitment,
attention, and resources from the top management of an organization.
Because it is clear that overall organizational cultural
competence will take both time and a better understanding of the potential
impact on outcomes and satisfaction, it is important to recognize the
role of health topic/cultural specific programs that have been supported
by governmental agencies and foundations. The OMH bilingual/bicultural
grants and the RWJ/Kaiser Opening Doors initiatives have
been promoted as models in a variety of venues. It is possible that, supported
by validating evaluative studies, successful replication of these programs
in other settings may encourage providers to go further in improving overall
access and services for diverse populations.
One example of these kinds of model approaches is the
increasing formation of and utilization of cultural brokers/case managers/outreach
community health workers. These individuals can, with proper training,
play a multi-functional role in bridging the gap between mainstream organizations
and ethnic communities. One example of this is the previously mentioned
Community House Calls program in Seattle; another is the well-developed
promotora model, which performs health education and outreach initiatives
in Latino communities. Their roles could be expanded to provide a number
of liaison functions in large and small organizations, especially those
that serve a number of different ethnic groups and may have difficulty
hiring bilingual/bicultural staff for all patient contact points.
1.7.2 Organizational Assessment,
Tools, Resources
As with the assessment of individual cultural competence,
there has been extensive development of organizational cultural competence
assessment tools and cataloging of those tools. The Judge Baker Children's
Center, and Mathematica Policy Research, Inc., actually focus
more on organizational assessment tools than individual tools. The Baker
Center uses an analysis of those tools has the foundation for an extensive
manual describing how children's mental health providers can conduct and
implement a culturally competent assessment process. The Mathematica collection
was actually compiled for its researchers to determine what domains of
cultural competence could be identified as the basis for a national survey
of linguistic and culturally appropriate services practiced by managed
care organizations. It is an explicit synthesis of cultural competence
assessment tools that could be the basis for a universal framework of
cultural competence definitions, assessment, standards development, and
policy (Appendix 10).
Several other assessment tools/processes are also spoken
of quite highly. One process developed by the HHS Maternal and Child
Health National Center for Cultural Competence has been conducted
with organizations in three states, with two additional states targeted
for this year. Another process developed by the National Public Health
and Hospital Institute was tested at a number of hospitals, and has
been redesigned as a organizational self-assessment tool. Miguel Tirado
has developed an assessment tool for managed care organizations based
on his previous individual health professional cultural competence assessment.
Iris Garcia of the Massachusetts Division of Medical Assistance,
has developed a tool for the state to use in assessing and rating the
cultural competence of hospitals, and is extending this work to eventually
include managed care organizations participating in Medicaid. Chris
Sandoval of Polaris Research in San Francisco offers an assessment
process for HIV services providers. Again, no research has specifically
validated one assessment process against another, and while several of
these tools/processes have benefited from the content developed by previously
published approaches, each reflects the specific definitions, goals, and
objectives of its authors rather than any universally accepted set of
criteria.
A few assessment tools/processes currently under development
will also be packaged with literature or recommendations on "best practices"
that will be selected by their authors for providers to use in improving
their programs. One promising document nearing completion is being developed
by Wendy Siegel for the Heartland Alliance of Illinois. This cultural
competence toolkit for managed care organizations will combine a blueprint
of organizational competencies, assessment criteria, and best practices
(Appendix 11).
In addition to assessment programs, there are a number
of other projects that offer information, resources, and technical assistance
on multicultural health topics. Among them are the OMH Resource Center,
the Cross-Cultural Health Care Program, HHS Maternal and Child Health
National Center for Cultural Competence (Appendix 12), The Texas
Department of Health Center For Cultural Competence, Polaris Research
(focused on HIV issues), Center for Cross Cultural Health, New York Task
Force on Immigrant Health (Appendix 13), Ethnomed, and Resources
for Cross Cultural Health Care and its online clearinghouse Diversity
Rx.
Summary Recommendations for 1.7
- Support evaluation of ethnic specific and multi-ethnic organizational
cultural competence models and practices.
- Support the compilation and dissemination of information on organizational
cultural competence model programs and practices, as well as on the
resource centers that may collect this information.
- Promote awareness of the value of organizational cultural competence
among provider organizations and management.
- Support consensus development of a universal framework of cultural
competence definitions, assessment, standards development, and policy.
- Promote use and dissemination of organizational assessment tools
and process to providers, managers, and provider organizations.
- Promote expansion of cultural brokers/ethnic community health worker
roles into multi-function cultural liaisons between provider organizations
and ethnic communities.
Contacts, Resources, References
1.7.1
Jean Gilbert, PhD
Kaiser Permanente
Cultural Competence
393 E. Walnut, LR-6
Pasadena, CA 91188-8361
Jean.Gilbert@kp.org
Harvard Pilgrim Health Care
Office of Diversity
10 Brookline Place West
Brookline, MA 02146-7229
617-730-7730
Association of Asian Pacific Community Health Organizations
1440 Broadway, Suite 510
Oakland, CA 94612
510-272-9536
New York Downtown Hospital
170 William Street
New York, NY 10038
212-312-5175
1.7.2
Dennis Andrulis, PhD
The New York Academy of Medicine
1216 Fifth Avenue
New York, NY 10029
212-822-7200
David Baker
Metro Health Medical Center
Case Western Reserve University
2500 Metro Health Drive
Cleveland, OH 44109-1998
216-778-3904
dwb@cwru.edu
Miguel Tirado, PhD
California State University--Monterey Bay
100 Campus Center
Seaside, CA 93955
408-582-3967
Wendy Siegel
Millenia Consulting
407 S. Dearborn, Suite 600
Chicago, IL 60605
312-922-9920
MILLENIA@IGC.APC.ORG
Bookda Gheisar
The Cross Cultural Health Care Program
Pacific Medical Center
1200 12th Ave. South
Seattle, WA 98144
Francesca Gany
New York Task Force on Immigrant Health
NYU School of Medicine
New York, NY 10016
212-263-8783
GANY@IS.NYU.EDU
Valerie Welsh
HHS Office of Minority Health
Rockwall II/5600 Fishers Lane, #1000
Rockville, MD 20857
301-443-9923
Iris Garcia
DMA-Office of Clinical Affairs
600 Washington St., 5th Flr.
Boston, MA 02111
617-210-5696
Tawara D. Taylor
MCH National Center for Cultural Competence
3307 M Street, NW
Washington, DC 20007
202-687-8807
HHS Office of Minority Health Resource Center
http://www.omhrc.gov
Ethnomed webpage
http://www.hslib.washington.edu/clinical/ethnomed/index.html
DiversityRx webpage
http://www.DiversityRx.org
Journey Towards Cultural Competency: Lessons Learned, National
MCH Resource Center on Cultural Competency, 1996, Texas Department of
Health.
Cross Cultural Competence Protocol, National Public Health
and Hospital Institute, 1995, Washington, DC.
Culturally Competent Health Service Delivery Under Managed
Care for Asians and Pacific Islanders, Association of Asian Pacific Community
Health Organizations, 1994.
Background Paper for the National Assessment of Linguistically
and Culturally Appropriate Services in Managed Care Organizations Serving
Diverse and Vulnerable Populations, by Amy Klein. Mathematica Policy Research,
Inc. Washington, DC 1998.
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