Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Chapter 1: Cultural and Linguistic Competency and the Centers of Excellence

Interest in the subject of cultural and linguistic competency is beginning to reach the “tipping point” (Gladwell, 2002). Over the past twenty years there has been an explosion of interest in developing programs that meet the general health, mental health, oral health, and social service needs of our Nation’s increasingly diverse population. Cultural and linguistic competence initiatives are underway at the systems, organizational, and clinical levels in a variety of institutions (The Commonwealth Fund. New York, NY, 2002). A growing number of Federal agencies, foundations, and private sector groups are supporting innovative educational, research, and service delivery activities.

This chapter covers the history of the COEs and their efforts to address health care disparities and cultural and linguistic competency, and also discusses a report on COE assessment and promising practices.

One such Federal agency is the Health Resources and Services Administration of the U.S. Department of Health and Human Services in Rockville, Maryland. HRSA’s understanding of cultural and linguistic competence is based largely on the work of Terry Cross and that of the Georgetown University National Center for Cultural Competence (NCCC). According to Cross, cultural and linguistic competence is a developmental process that evolves over time. Both individuals and organizations begin this process with various levels of awareness, knowledge, and skills along the cultural and linguistic competence continuum (adapted from Cross et. al., 1989). Cross et al. defines cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enable that system, agency or those professionals to work effectively in cross-cultural situation.”

By considering other definitions of cultural and linguistic competence, it is possible to draw a more complete picture of the state of cultural and linguistic competence in health care educational settings. For example, in 2002 the Commonwealth Fund in New York said cultural competence is “the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery of care to meet patients’ social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, or English proficiency.”

Similarly, the American Medical Association in Chicago said in a 1994 publication, Culturally Competent Health Care for Adolescents, that cultural competence is “the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences; self-awareness; knowledge of the patient’s culture; and adaptation of skills.”

Linguistic competency, while linked to cultural competency, requires additional skills and understandings. Kaiser Permanente, the large non-profit managed care organization in Oakland, Calif., defines linguistic competence in its National Linguistic & Cultural Programs, National Diversity, (2003), saying:

“Linguistic competence recognizes that language and culture are interconnected. Language reflects culture while shaping it at the same time. Culture shapes our thinking, which in turn shapes our language. This powerful interrelationship affects all human interactions. Linguistic competence involves more than just the ability to speak and understand another language. It involves the knowledge of the cultural orientation that helps create meaning from language.

Void of the ability to communicate in a common language, people are forced to cope with limitations that are disorienting, frustrating, and stressful. Dealing with these limitations at a time of illness or duress has a direct impact on the quality of care a patient can receive, and the health system’s ability to provide basic good medicine. A linguistically competent health care professional understands the intrinsic cultural meaning of a message and is able to elicit and send the right cultural response. This can be accomplished by sharing the same language and cultural understanding, or, by taking action to obtain appropriate assistance in facilitating intercultural communications. Thus, a health care professional’s level of linguistic competence depends on personal knowledge, skills, and attitude. The appropriate action is optimized by a linguistically competent system of care or hindered by its absence.”

The National Center for Cultural Competence at the Georgetown University Center for Child and Human Development defines linguistic competence as: “The capacity of an organization and its personnel to communicate effectively and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. The organization must have a policy, structures, practices, procedures, and dedicated resources to support this capacity.” (Goode & Jones, NCCC, August 2003)

Definitions of other key terms related to cultural and linguistic competence can be found in the glossary in Appendix B of this curriculum.

In summary, cultural and linguistic competence is a process that involves an ongoing commitment by individuals and organizations to develop the requisite knowledge, skills, and attitudes and to promote programs and systems that ensure that all individuals receive the highest quality health care. Aspiring to cultural and linguistic competence also involves a tremendous commitment of both people and resources. Among those organizations that have made such a commitment to cultural and linguistic competence is the HRSA’s Centers of Excellence (COE).

I. The History of COEs: Efforts to Address Health care Disparities and Cultural and Linguistic Competency

HRSA Centers of Excellence (COEs) have a close and necessary involvement in cultural and linguistic competence. In 1991, HRSA instituted the Centers of Excellence (COE) Program, designed to support programs of excellence in health professional education for underrepresented minorities (URM) in health professional schools of medicine, dentistry, pharmacy, and mental health. Eligible applicants are accredited allopathic schools of medicine, osteopathic medicine, dentistry, pharmacy (PharmD programs only), graduate programs in behavioral or mental health, or other public and nonprofit health or educational entities including faith-based organizations and community-based organizations that meet the requirements of section 736(c) of the Public Health Service Act, as amended.

Housed in HRSA’s Bureau of Health Professions, Division of Health Careers Diversity and Development, the COE program was among the earliest Federal grantee projects that required recipients to address the cultural and linguistic competency training of individuals in their respective schools. The COE Program was established to be a catalyst for institutionalizing a commitment to URMs and to serve as a National resource and educational center for diversity and minority health issues.

The goals of the COEs are to demonstrate:

• Institutional commitment to underrepresented minority (URM) populations with a focus on minority health issues and eliminating health disparities
  
• Innovative methods to strengthen or expand educational programs to enhance academic performance of URM students of the school
  
• The presence of culturally competent health professions educators, students, and graduates of the school
  
• Models of URM faculty development and retention, multicultural curricula, and faculty and student research as it relates to minority health issues

Although the COE Program encompasses many goals, the incorporation of cultural and linguistic competence training in 1991 was visionary for its time. Since 1991, there have been many critiques of the Nation’s health care delivery system, such as the Institute of Medicine’s (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, National Academies Press, (2003), In the Nation’s Compelling Interest: Ensuring Diversity in the Health- Care Workforce (2004), Crossing the Quality Chasm: A New Health System for the 21st Century (2001), and Missing Persons: Minorities in the Health Professions, A Report of the Sullivan Commission on Diversity in the Health care Workforce (2004).

In its report, Unequal Treatment, the IOM included the following critical findings: Racial and ethnic disparities in health care occur within the context of broader historic and contemporary social and economic inequality and evidence of persistent racial and ethnic discrimination in many sectors of American life.

• Many factors—including health systems, health care providers, patients and utilization managers—may contribute to racial and ethnic disparities in health care
  
• Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care
  
• Sociocultural differences between patient and provider influence communication and clinical decision-making
  
• A significant body of literature defines and supports the importance of cross-cultural education in the training of health professionals
  
• Cross-cultural education offers promise as a tool to improve the ability of health professionals to provide quality care to diverse patient populations, thereby reducing health care disparities

For COEs, cultural and linguistic competency training has become one of the foundations upon which to address the disparate care provided to some patients and to underrepresented minorities in particular. When the COEs opened, the directors and staff of the centers immediately understood the tremendous challenge of the cultural and linguistic competence mandate. Among the COEs, for example, there was a paucity of underrepresented minority faculty recruitment and development programs and a limited number of recognized programs related to cultural and linguistic competency knowledge, skills, and expertise. As a result, the faculty and administration of the COEs have taken modest incremental steps over the past 14 years to develop and teach cultural and linguistic competency.

For the majority of COEs, cultural and linguistic competency education began with an elective offering for those students who had an interest in this area. In other words, these programs were attempting to do little more than “preach to the choir.” Over the first decade, however, as institutions began to understand the COE initiative and purpose, COEs became better positioned within their organizations. This improved positioning enabled the faculty of some COEs to implement cultural and linguistic competency programs and activities that positively affected individual students and, in some cases, faculty. However, the implementation of cultural and linguistic competency training was unevenly developed across COEs.

Today, health care professionals and educators in a prospective COE understand that developing a center of excellence requires making a strong commitment to addressing health disparities in a way that many institutions have not yet fully embraced. These professionals and educators must be willing to break down the barriers that exist in institutions, groups, and among individuals, and they must recognize the opportunities that exist in accepting that developing cultural and linguistic competency will result in delivering quality care for all. Additionally, they must also accept the challenge of promoting their cultural and linguistic competency efforts so that they can help others learn the lessons they have learned in the process of developing such competency.

Since all significant change initiatives encounter resistance, practitioners and educators employed at COEs must be prepared to meet and respond to such resistance with consistent and well-planned efforts to achieve culturally and linguistically competent health care delivery in the United States.

II. COE Assessment and Promising Practices Report Results

In the spring of 2004, Magna Systems, Inc., under contract with the HRSA Division of Health Careers Diversity and Development, conducted an assessment of the cultural and linguistic competence activities of HRSA Centers of Excellence (COE) grantees. This assessment used the 2001-2002 Uniform Progress reports, which the COE grantees complete annually. The assessment examined reports from twenty-nine COEs. The activities were coded and cataloged according to an assessment matrix, which was developed by the Expert Team of this contract. The matrix was arranged by topic: content, teaching delivery/methods, non-teaching delivery/methods, and evaluation.

Some of the main findings include:

• The topic taught with the most frequency among the twenty-nine COEs was “Different Population Groups.” This topic includes the general health-related and cultural beliefs of an ethnic group, as well as instruction on diversity and multiculturalism.
  
• The teaching method the COEs employed most frequently was “Classroom-Directed Learning.” This includes classroom-directed learning that has been incorporated into the curriculum either as a required course, elective, or unit in an established course.
  
• The non-teaching method used most frequently was “Research Pertaining to People of Color.” This category is meant to determine the COEs’ activities around academic or community-based research pertaining to people of color.
  
• A few COEs conducted evaluations of their programs. Three COEs conducted an evaluation of their cultural and linguistic competence curricula.

These findings demonstrate important achievements among the efforts of COEs to achieve and promote cultural and linguistic competence. The complete COE Assessment and Promising Practices Report is provided in Appendix C of this curriculum guide.