Cultural and Linguistic Competencies: Health and Health Care

HEALTH AND HEALTH CARE
Recommendations, benchmarks and best practices for cultural competence abound. This section is a compilation of resources that highlight approaches to cultural competency in health and health care. Most resources discuss the importance of focusing on the following areas: 1) values and attitudes; 2) staff recruitment and retention; 3) staff education and development; 4) communication; 5) planning, monitoring and evaluation; 6) organizational infrastructure; 7) services and intervention; and 8) linguistic capacity. A common limitation of the current literature is an overall lack of assessment in these areas to connect interventions to a reduction in racial and ethnic disparities in health and health care. As organizations move forward with their own initiatives to address cultural and linguistic competency, measuring the effectiveness of programs and policies should be an area of focus.

? Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J. Culturally competent health care systems: A systematic review. American Journal of Preventive Medicine [serial online]. 2003;24(3S):68-79. Available at: http://minority-health.pitt.edu/archive/. Accessed May 18, 2007.

In this article, the authors review five interventions to improve cultural competency in health care systems: 1) recruitment of a culturally diverse workforce, 2) availability of interpreters or bilingual staff who speak the clients’ languages, 3) cultural competency training for healthcare providers, 4) development of appropriate education materials and 5) providing a culturally specific health care setting (i.e., clinicians of the same culture group as clients). Due to a limited number of studies that measured outcomes of interest, the authors were unable to determine the effect of each of these interventions in three key outcome areas: client satisfaction, racial and ethnic differentials in health care utilization, and treatment and improvements in health status. The authors argue that future studies must assess patient outcomes, not only changes in provider knowledge and attitudes. They make recommendations for research questions related to cultural competence and outcomes.
Beach MC, Gary TL, Price EG, Robinson K, Gozu A, Palacio A, Smarth C, Jenckes M, Feuerstein C, Bass EB, Powe NR, Cooper LA. Improving health care quality for racial/ethnic minorities: A systematic review of the best evidence regarding provider and organization interventions. BMC Public Health [serial online]. 2006;6:104. Available at: http://www.pubmedcentral.nih.gov/. Accessed May 18, 2007.

This article synthesizes the findings from studies of interventions targeted at health care providers to improve health care quality or reduce disparities for racial or ethnic minorities. Despite the paucity of evidence-based studies, several promising strategies may improve health care quality for racial and ethnic minorities. These strategies include provider reminder systems for standard services, offering preventive services directly to patients, use of simultaneous interpretation and use of structured questionnaires. Combining multiple strategies may be even more beneficial.
? Betancourt JR, Green AR, Carrillo JE. Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund; 2002. Available at: http://www.cmwf.org/. Accessed May 18, 2007.

To help address the questions of how to make health care systems more culturally competent and what future physicians should be taught about cultural competence, this field report explores the many definitions of cultural competence. The report also aims to identify the benefits of and barriers to achieving a culturally competent care system. The authors studied four models (one in academia, one in government, one a managed care system and the fourth a community health model) and make recommendations about what factors need to be in place to achieve organizational, systemic and clinical cultural competence.
? Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports [serial online]. 2003;188:293-302. Available at: http://www.publichealthreports.org/userfiles/118_4/118293.pdf. Accessed May 18, 2007.

For this article, the leaders in cultural competency framework development surveyed the medical and public health literature for answers to two questions: 1) What are the major components of cultural competency? and 2) How do we incorporate culturally competent interventions into the delivery of health care? The authors identified three major levels of health care at which sociocultural barriers contribute to disparities in health and health care: organizational (leadership and workforce), structural (processes of care) and clinical (provider-patient encounters). The authors’ recommendations include: hiring more people of color in health professions, developing interpreter services and culturally and linguistically appropriate health education materials and providing education on cross-cultural issues to health care providers.
? Brach C, Fraser I. Can cultural competency reduce racial and ethnic disparities? A review and conceptual model. Medical Care Research and Review. 2000;57(S1):181-217.

In this seminal article, a comprehensive literature review found that cultural competence has not been linked to patient outcomes and tends to focus only on the individual (patient or provider), rather than the system in which the individual participates. The literature is weak on identifying sources of disparities, and almost no literature focuses on techniques to reduce disparities. Drawing upon the literature, the authors provide a conceptual model and evidence of ways in which the cultural competency techniques most often cited in the literature (e.g., interpreter services, recruitment and retention, training, coordinating with traditional healers, hiring community health workers, culturally competent health promotion, including family members in the care model, immersion into another culture, administrative and organizational accommodation of cultural differences) theoretically could affect the processes (and therefore outcomes) of care for racial and ethnic minorities.
? Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing. 2002;13(3):181-184.

This seminal article outlines the author’s cultural competency model that views cultural competence as an ongoing process for the health care provider, consisting of cultural awareness, cultural knowledge, cultural skill, cultural encounters and cultural desire. The author stresses that there is more variation within ethnic groups than across ethnic groups, that cultural competence is essential and that there is a direct relationship between the level of competence and the ability to provide effective culturally responsive services.
The Commonwealth Fund. The role and relationship of cultural competence and patient-centeredness in health care quality. Beach MC, Saha S, Cooper LA, eds. New York: The Commonwealth Fund; 2006. Available at: http://www.commonwealthfund.org/. Accessed May 18, 2007.

This report explores the historical evolution of patient-centered care. Early models focused on provider-patient interactions, whereas current models focus on how patients are treated by the health care system as a whole. The authors advocate that combining patient-centered approaches with the principles of cultural competence may be a promising approach for improving the quality of health care.
The Commonwealth Fund. Improving quality and achieving equity: The role of cultural competence in reducing racial and ethnic disparities in health care. Betancourt JR, ed. New York: The Commonwealth Fund; 2006. Available at: http://www.commonwealthfund.org/. Accessed May 18, 2007.

This report reviews the principles of quality of care and the evidence for the existence and root causes of racial and ethnic health disparities. It provides a framework and recommendations to link the quality-of-care and cultural competence movements and outlines hypothetical and proven strategies for delivering high quality, culturally competent care.
Geiger HJ. Racial stereotyping and medicine: The need for cultural competence. Canadian Medical Association Journal [serial online]. 2001;164(12):1699-1700. Available at: http://www.cmaj.ca/cgi/reprint/164/12/1699. Accessed May 22, 2007.

This commentary by a noted health disparities researcher proposes that lack of cultural competence may be the most remediable cause of health disparities if honestly recognized and addressed in health care systems. The current movement toward acknowledgement of the need for cultural competency training among health care professionals and international consideration of institutional racism as a factor in creating disparities are described as encouraging signs of progress. The author advocates for more evaluation with an emphasis on health outcomes.
Goode TD, Dunne MC, Bronheim SM. The evidence base for cultural and linguistic competency in health care. New York: The Commonwealth Fund; 2006. Available at: http://www.commonwealthfund.org/. Accessed May 21, 2007.

This report reviews the published scientific literature for evidence of the impact of cultural and linguistic competency on health outcomes, as well as the cost-benefit ratio of such competency for the health care system. The majority of literature focuses on the concept of cultural competency, without considering health outcomes and cost-benefit issues. The authors identify gaps in the literature and make recommendations for future research.
Kim-Godwin YS, Clarke PN, Barton L. A model for the delivery of culturally competent community care. Journal of Advanced Nursing. 2001;35(6):918-925.

This article describes a process for developing and testing a culturally competent community care model for community health nurses working with diverse populations. Dimensions of the model include: caring, cultural sensitivity, cultural knowledge and cultural skills. The model emphasizes the relationship between cultural competence and health outcomes.
? Leininger M. Towards conceptualization of transcultural health care systems: Concepts and a model (classic article from 1976). Journal of Transcultural Nursing. 1993;4(2):32-40.

This seminal article, in what would become known as the field of “cultural competency,” was originally published in 1976. Drawing from both anthropological and nursing perspectives, the author identified major trends, challenges and concepts related to trans-cultural health care, an evolving body of knowledge and practices regarding health and illness care patterns from a comparative perspective. The author’s conceptual model defines four distinct levels of analysis: 1) social structure (political, economic, religious, technological, educational); 2) cultural values, beliefs and the meaning of health and care and how it is expressed; 3) health care systems (traditional and modern) and their features (holistic versus compartmentalized) and 4) roles, functions and activities of health providers and client outcomes.
Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. Journal of General Internal Medicine [serial online]. 2004;19:101-110. Available at: http://www.pubmedcentral.nih.gov/. Accessed May 18, 2007.

This articles reports on the findings of the 2001 Commonwealth Fund Health Care Quality Telephone Survey to assess racial and ethnic differences in patients’ perceptions of primary care providers. The findings showed that African Americans, Hispanics and Asians were more likely than Whites to perceive that 1) they would have received better medical care if they belonged to a different racial or ethnic group and 2) medical staff treated them unfairly or with disrespect based on race, ethnicity or how well they spoke English.
Napoles-Springer AM, Santoyo J, Houston K, Perez-Stable EJ, Stewart AL. Patients’ perceptions of cultural factors affecting the quality of their medical encounters. Health Expectations [serial online]. 2005;8:4-17. Available at: http://repositories.cdlib.org/. Accessed May 18, 2007.

Recognizing that most cultural competency research is conducted from the perspective of the provider, these authors set out to understand the perspectives of patients in three ethnic groups. Nineteen focus groups were conducted with a sampled group of diverse participants recruited from a wide variety of settings in the San Francisco area. Specific recommendations for ways in which providers could enhance the quality of medical encounters included: being sensitive to patient privacy, using a humanistic approach and treating patients as equals.
Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: Defined and demystified. Ethnicity and Disease. Winter 1999;9:10-21.

In this article, health communication researchers described a framework for developing culturally sensitive public health programs. Within this framework, cultural sensitivity has two dimensions: 1) surface structure, which refers to matching intervention materials and messages both to the target group’s observable, “superficial” characteristics (e.g., language, music, food, clothing) and to appropriate avenues for message or program delivery (e.g., churches, schools) and 2) deep structure, which refers to understanding the core cultural values; explanatory models; and social, historical, environmental and psychological forces that influence the health behavior of the target population. Focus groups and pre-testing can help practitioners address both surface and deep structures during interventions. This article also describes some of the model’s limitations, such as conflict between public health goals and cultural values, and the limited research about the efficacy of cultural competency interventions.
Shen Z. Cultural competence models in nursing: A selected annotated bibliography. Journal of Transcultural Nursing. 2004;15(4):317-322.

This annotated bibliography was compiled to reflect the current status of research on cultural competence in nursing. The focus is on book literature, supplemented by journal articles, that emphasizes the construction, development or conceptualization of cultural competence models and cultural competency assessment models and guides.

Watson SD. Equity measures and systems reform as tools for reducing racial and ethnic disparities in health care. New York: The Commonwealth Fund; 2005. Available at: http://www.commonwealthfund.org/. Accessed May 21, 2007.

This report advocates for reform in the Medicare and Medicaid systems. It provides a template for new administrative policies that mandate quality assessment and performance improvement initiatives to reduce racial and ethnic disparities in health care, and recommends policy and accreditation mandates and financial incentives to encourage health care systems to adopt performance measures that track data by race and ethnicity.

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