Attachment 1: Annotated Bibliography

Core Models and Methods

Baker C (1997). Cultural relativism and cultural diversity: Implications for nursing practice. Advances in Nursing Science, 20(1), 3-9.

This article examines the doctrine of cultural relativism in nursing practices. Cultural relativism is defined as the perspective that the behaviors of individuals should be judged only from the context of their own cultural system. The terms refer to the use of one’s own culture as the starting point to judge other cultures and to the assumption that one’s own culture is superior to other cultures. The article examines the dilemmas faced by nurses in making judgments in cross-cultural situations and suggests drawing on the hermeneutic approach as a philosophy for cultural encounters. The hermeneutic approach deals with how one person comes to understand the actions, words, or any other meaningful product of another person. At the heart of the hermeneutic perspective is constructive communication across cultures.

Brink PJ (1999). Transcultural versus cross-cultural. Journal of Transcultural Nursing, 10(1), 7.

The article is a short discussion of the terms transcultural and cross-cultural. It defines transcultural as the belief in concepts that transcend cultural boundaries. In contrast, the author places cross-cultural in the context of anthropological research that compares and contrasts cultural groups with each other.

Campinha-Bacote J (1994). The process of cultural competence in health care: A culturally competent model of care. Perfect Printing Press. Wyoming, OH.

Campinha-Bacote presents a culturally competent model of care with four components on a continuum: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill and (4) cultural encounters. Cultural awareness is defined as having cultural sensitivity and avoiding cultural biases. Cultural knowledge is defined as the care provider understanding the cultural would view and theoretical/conceptual framework of the patient. Cultural skill is defined as the provider having developed the skill-set to access an individual’s background and formulate a treatment plan that is culturally relevant. Cultural encounters are the processes which allow the health care provider to directly engage in cultural interaction with clients from culturally diverse backgrounds. Additionally the article provides a checklist of the “Six A’s for Culturally Responsive Services” as a as keys to providing access of services to underserved and culturally/ ethnically diverse populations. The six A’s are: (1) available, (2) accessible, (3) affordable, (4) acceptable, (5) appropriate, and (6) adoptable.

Campinha-Bacote J (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38(5), 203-207.

This article presents the author’s Inventory to Assess the Process of Cultural Competence (IAPCC) among healthcare professionals, an instrument that measures the constructs of cultural awareness, cultural knowledge, cultural skill, and cultural encounters among health care professionals. The IAPCC is a self-administered survey that uses a 4-point Likert scale to score 20 different items. These 20 items address each of the four constructs. The full instrument is not included.

Carballeira N (1997). The LIVE and LEARN model for cultural competent family services. Continuum, 17(1), 7-12.

The author applies a model of cross-cultural attitudes to shed light on what happens whenever a provider and a client from different cultures meet. The author suggests that whenever the provider manifests a cultural attitude, the client exhibits some reaction. The model of cross-cultural attitudes and client reactions fall in a range from superiority – incapacity – universality – sensitivity – to competence, whereas the client reactions range from resistance – accommodation – to adaptation. The author proposes the LIVE & LEARN model which stands for: Like- Inquire – Visit – Experience and Listen – Evaluate – Acknowledge – Recommend – Negotiate. The model presents providers with a practical, phased approach to cross cultural service delivery that respects client centrality, avoids stereotyping, and leads to the adoption of mutually acceptable objectives and measures for changed behavior.

Cross TL, Bazron BJ, Dennis KW, Isaacs MR (1999). Toward a culturally competent system of care, volumes 1 and 2. National Institute of Mental Health, Child and Adolescent Service System Program (CASSP) Technical Assistance Center, Georgetown University Child Development Center. Washington, DC.

This monograph outlines a philosophical framework for developing and implementing a service delivery system that provides services in a culturally appropriate way in order to meet the needs of culturally and racially diverse groups. The authors developed a comprehensive cultural competence model that can be used to assist health care professionals to work effectively in cross-cultural situations. The monograph sets forth a six point cultural competence continuum and, outlines the five essential elements that contribute to a system’s or agency’s ability to become more culturally competent, and identifies a set of underlying values that must be present in a culturally competent system of care. In addition, the authors provide some practical ideas for improving service delivery at the policymaking, administrative, practitioner, and consumer level.

Klein A, Marie-Martinez R, Lacerino-Paquet N (1998). Background paper for a national assessment of linguistically and culturally appropriate services in managed care organizations serving racially and ethnically diverse communities. Prepared by Mathematica Policy Research, Inc. for the U.S. Department of Health and Human Services.

This article is a review of the current literature that defines and describes the nature and extent of linguistic and cultural appropriateness in health care and that links such services to patient and health outcomes. The paper provides a series of definitions for linguistically appropriate services, a discussion of the alternative language used for addressing the concept of cultural competence, and addresses the different service models of culturally appropriate care.

Jones M, Bond M, Cason CL (1998). Where does culture fit in outcomes management? Journal of Nursing Care Quality, 13(1), 41-51.

The authors describe the concept of cultural competence and ways in which culture is important to the delivery of culturally competent care. The authors propose strategies for developing a culturally competent work force; drawing lessons from on ongoing projects in the United States and the fields of clinical enthography and anthropological research.

Leininger M (1993). Towards conceptualization of transcultural health care systems: concepts and a model. Journal of Transcultural Nursing, 4(2), 32-40.

The Sunrise Model is a comprehensive guide for nurses to use in conducting a cultural care assessment. The model is based on six domains: (1) culture values and lifeways; (2) religious, philosophical, and spiritual beliefs; (3) economic factors; (4) educational factors’ technological factors; (5) kinship and social ties; and (6) political and legal factors. It also describes three modalities that can guide nursing interventions so as to provide culturally appropriate care: (1) cultural care preservation and/or maintenance; (2) cultural care accommodation and/or negotiation; and (3) cultural care re-patterning or restructuring. Not all three modalities may be necessary to achieve cultural competent care. 

Office of Minority Health (1999). Assuring cultural competence in health care: Recommendations for national standards and outcomes-focused research agenda. Recommended Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care Services. Prepared for the U.S. Department of Health and Human Services. Washington, DC. 

This report responds to the need to develop consensus and standards regarding what constitutes cultural or linguistic competence in health care service delivery. This report outlines a set of 14 standards for use by various stakeholders, including providers, policymakers, accreditation and credentialing agencies, purchasers, patients, advocates, educators and the health care community in general. The expectation is that the standards will provide guidance to providers on how to provide culturally competent care and provide policymakers and consumers with the tools to evaluate and assess whether a provider is delivering culturally competent care. The recommended standards were developed with input from a national advisory committee of policymakers, health care providers, and researchers. The process used in developing the standards included the formulation of research questions and a review of technical and policy literature to identify categories of cultural competence. A content analysis of the literature was conducted which identified two thematic clusters corresponding to (1) linguistic competence (i.e., language access, interpreter and translation services) and (2) cultural competence (i.e., patient, staff and organizational cultural diversity management). An initial list of 21 draft standards was consolidated to 14 standards. The standards relate to a variety of areas, including policies and organizational structures, consumer involvement, training and education of staff, and the provision of interpretation services. Along with recommended national standards, the report also outlines a research agenda for relating the standards to outcomes.

Pachter LM (1994). Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. JAMA, 271(9), 690-694.

This article presents an approach to evaluation of patient-held beliefs and behaviors that may not be concordant with those of medical doctors. Most clinical encounters can be analyzed as an interaction between the “culture of medicine” and the “culture of patients.” These two groups have different beliefs, attitudes, and knowledge; physicians and patients often have different ways of conceptualizing a sickness episode. Illnesses that do not fit into any biomedical disease category are often called “folk illnesses”. The authors present several reasons for health care providers to know about folk illnesses and suggest that clinicians need to become aware of commonly held folk beliefs, assess the likelihood of a patient acting on those beliefs, and arrive at a way to negotiate between the belief systems.

Pachter LM (1993). Folk illnesses: methodological considerations. Medical Anthropology, 15, 103-107.

This paper suggests that methodologies to study the concepts and beliefs behind illness are becoming increasingly sophisticated. Brief explanations of different methodologies cover exploration of the relationship between individual informant responses and underlying cultural beliefs; cross-cultural variation in folk-illness beliefs; and analysis of the interface between folk-illnesses and biomedicine. The author emphasizes that researchers need to constantly explore new methodologies when studying folk illnesses.

Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL (1999). Cultural sensitivity in public health: defined and demystified. Ethnicity and Disease, 9(1), 10-21. Review.

This article describes various concepts that are related to cultural competence and draws from sociological and linguistics theory to delineate between two levels of cultural competence (surface and deep). In examining how to implement interventions, the authors suggest using focus groups and pre-testing.

Roberson MR, Kelley JH (1996). Using Orem’s theory in transcultural settings: a critique. Nursing Forum, 31(3), 22-28.

This article presents a critical analysis of Orem’s Self Care Deficit Theory of Nursing for use with culturally diverse populations. The article applies the theory to examples from multiple international communities, including two examples of communities in the United States (Navajo and Puerto Rican). The authors state the limitations of Orem’s theory lie in the failure to include a discussion of how culture impacts health care, of what specific knowledge base is required to perform a cultural assessment, and of what needs to be incorporated into a cultural assessment.

Shapiro J, Lenahan P (1996). Family Medicine in a culturally diverse world: a solution oriented approach to common cross-cultural problems and medical encounters. Family Medicine, 28, 149-155.

This article identifies general strategies that can be applied by medical residents when approaching cross-cultural encounters. The authors caution against using the traditional “universalistic perspective,” whereby cultural differences are all but ignored and interpretations and interventions inconsistent with a patient’s belief system are imposed on the patient. Instead, the authors explore the “culture-specific” model where residents begin to develop efficient, solution-oriented ways of using cross-cultural principles to guide patient-physician interactions. The authors caution against indulging in a simplistic “cultural elements” approach whereby residents are encouraged to become familiar with a vast array of cultural variation. Instead, the authors suggest: (1) evidence-based evaluation of cultural information whereby residents identify particular cultural constructs that have clear behavioral/social implications; and (2) inductive models of learning whereby the patient, rather than theory, is the starting point for discovery and residents observe patient behavior and form conclusions that apply to the patient.

Smith LS (1998 Spring). Concept analysis: cultural competence. Journal of Cultural Diversity, 5(1), 4-11.

This article examines the concept of cultural competence and attempts to clarify the term as used in health care literature that explores the race-culture comparative paradigm. The author describes various components of cultural competence including the events, ideas, conditions, and behavior that must occur for cultural competence to occur, and the consequences of cultural competence. The importance of developing methods for measuring cultural competence and the creation of empirically based standards for cultural competence are discussed.

Shumaker RP (1998). Multicultural needs bring on new opportunities. AORN Journal, 68(5), 744-746.

This is an editorial exploring the need for understanding transcultural care. In this article cultural competence is defined as the ability to deal with individuals on different levels, ranging from a transcultural assessment to identifying factors such as religious views or folk cures that may influence a patients behavior when ill.

Tirado M (1998 December). Monitoring the managed care of culturally and linguistically diverse populations. Health Resources and Services Organization. The National Clearinghouse for Primary Care Information , Washington DC.

This study develops culturally sensitive self-assessment tools which both individual health practitioners and plan managers can use to better understand the process of delivering health care to culturally and linguistically diverse communities. The tools were tested by a group of mental health care professionals to determine the relevance of the instruments in a variety of health care settings. With the collaboration of these groups, the professionals discussed the organizational challenges managed care plans face in seeking to address the needs of limited and non-English speaking members systematically. The study promotes “customized care” efforts that promote an individualized approach to caring for plan members and for supporting the professional staff assigned to serve them.

West EA (1993). The cultural bridge model. Nursing Outlook, 41(5), 229-234.

The authors explore the application of the cultural bridge model to providing nursing care to Native American Indians. The model is based on the concept of mutual respect and builds on the idea of maintaining cultural differences and uniqueness while having a meaningful relationship with people of differing cultures.

Assessment Tools and Evaluative Models [1]

Behui K, Bhugra D (1997). Cross-cultural competencies in the psychiatric assessment. Journal of Hospital Medicine, 57(10), 492-496.

This article outlines the essential features in contemporary psychiatric practice to which one must attend when patient and professionals do not share the same culture. The authors draw upon Kleinman’s explanatory model that argues that patients have a unique set of beliefs about the causation of their change in function and emotional experience, and this determines who they think are appropriate care givers for the healing process.

Bravo M, Canino GJ, Rubio-Stipec M, Woodbury-Farina M (1991). A cross-cultural adaptation of a psychiatric epidemiology instrument: the diagnostic interview schedule’s adaptation in Puerto Rico. Culture Medicine and Psychiatry, 15(1), 1-18.

This article illustrates the application of a comprehensive cross-cultural adaptation model of the Diagnostic Interview Schedule (DIS) to both the translation into Spanish and the adaptation to a population of Puerto Ricans.

Browne AJ (1997). A concept analysis of respect applying the hybrid model in cross-cultural settings. Western Journal of Nursing Research, 19(6), 762-780.

The article deconstructs “respect” as a concept in the domain of nursing using the hybrid model of concept development, illustrated with examples from two different cross-cultural settings. The authors point out that conveying respect during cross-cultural interactions, and to marginalized or disadvantaged patients, maybe be particularly challenging specifically because manifestations of respect may be dependent on culturally specific norms of interacting.

Broughton BK, Lutner N (1995). Chronic childhood illness: a nursing health promotion model for rehabilitation in the community. Rehabilitation Nursing, 20(6), 318-322.

This articles presents a model for culturally competent nursing that attempts to blend health education with achievable health promotion activities, while respecting cultural differences. It accounts for the interdisciplinary influence of care providers, community members, culture, the family, and the individual.

Campbell JC, Campbell DW (1996). Cultural competence in the care of abused women. Journal of Nurse-Midwifery, 41(6), 457-62.

This article discusses the principles of cultural competence, abuse, and empowerment as the basis for a model designed for nurse-midwives who provide clinical intervention to abused women. The discussion of cultural competence is based on models by Campinha-Bacote and Rorie, et al. The article concludes that nurse-midwives interact with women at a stage of life when they are particularly invested in family and children, and that a culturally competent assessment of the family unit enhances the probability of accurate assessment and effective intervention in care of abused women.

Campinha-Bacote J, Yahle T, Langenkamp M (1996 March-April). The challenges of cultural diversity for nurse educators. Journal of Continuing Education for Nurses, 27(5), 59-64.

The authors demonstrates how Campinha-Bacote’s model can provide nurse educators with a framework for teaching nurses how to deliver culturally competent care. Cultural competence is defined as a process, in which the nurse continuously strives to achieve the ability to effectively work within the cultural context of an individual, family, or community with a diverse cultural and ethnic background. The authors make recommendations for cultural diversity educational programs such as; considering the culture of the hospital setting prior to implementation; using teaching from a culturally competent instructor; being offered on a voluntary basis; incorporating creative and non-threatening experiential exercise (such as cultural bingo, humor therapy, etc); and providing a positive learning experience.

Carrillo JE, Green AR, Betancourt JR (1999). Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine, 130(10), 829-835.

This article presents a structure for a cross-cultural curriculum that assists physicians in understanding how a patient’s socio-cultural background affects his or her health beliefs and behaviors. The curriculum is grounded in ethnographic theory as well as medical interviewing techniques. The curriculum is comprised of a set of concepts and skills taught in 5 modules over four 2-hour sessions. Module 1 defines culture and assists participants in exploring their personal culture and the “medical culture” and discusses the attitudes that are fundamental to cross-cultural encounters. Module 2 explores “core cultural issues” or situations, interactions, and behaviors that have potential for cross-cultural misunderstanding. Module 3 focuses on patients’ explanatory models of illness, how the participants can explore it with individual patients, and how it effects the physician-patient encounter. Module 4 assists participants in defining and managing the patient’s social context, or the social factors that are most relevant to the medical encounter. The final module, the capstone of the training, draws on the skills learned in the previous modules and teaches participants to facilitate and negotiate cross-cultural encounters.

Community and Family Health Multicultural Workgroup, Washington State Department of Health (1995). Building cultural competence: A blueprint for action. Prepared by the National Maternal and Child Health Resource Center on Cultural Competency.

This report provides specific examples of effective state strategies in addressing the needs of diverse growing populations, as well as challenges that any state would face in this process. The report discusses the specific process followed by the Community and Family Health staff of the Washington State Department of Health. It is a blueprint that can be adapted to suit the specific needs of agencies. The report emphasizes that acquiring cultural competence is a process that requires participation at all levels of an agency from the individual to the organizational level. The report includes references the workgroups found useful and appendices, which include relevant definitions, illustrations, guidelines and forms.

Cultural Competence Strategic Framework Task Force, New York State Office of Mental Health (1997). New York state cultural and linguistic competency standards. Prepared for the New York State Office of Mental Health. New York, NY. 

This report is the result of a workshop in which participants worked to develop performance measures to assess compliance with cultural competence standards. The workgroup defined five domains of cultural competence: accessible inpatient, outpatient, and community support services; qualified interpreters; involvement of enrollees and families role in service development; culturally and linguistically competent evaluation, diagnosis, treatment and referral service; and membership satisfaction.

Cultural Competency Subcommittee for the Hispanic Agenda for Action, Department of Health and Human Services (1998). Recommendations on cultural competency. Prepared for the Department of Health and Human Services. Washington, DC.

This article represents the framework developed by a cultural competence subcommittee for the HHS 1998 Hispanic Agenda for Action initiative. The subcommittee cited the need for an HHS adopted definition of cultural competence, a coordinated HHS approach to cultural competence, and general awareness as reasons for its work. This article provides an inventory of cultural competence activities across HHS agencies that include: policies, mission/principles, standards, guidelines, performance measures, cultural competence workgroups and initiatives, provision of program information in languages other than English, employment of bilingual staff, training of staff on culturally diverse populations, language development courses, publications on cultural competence, and funding for cultural competence initiatives.

Davidhizar R, Giger JN (1998). Transcultural patient assessment: a method of advancing dental care. The Dental Assistant, 67(6), 34-43.

This article is an analysis of the Davidhizar and Giger model for cultural competent care in oral health services. The article emphasizes that it is essential for persons who work in a dental office to understand the differences in individuals from culture to culture. It is also important to appreciate that each patient and family is culturally unique and brings this uniqueness to the dental office.

DeSantis L (1994). Making anthropology clinically relevant to nursing care. Journal of Advanced Nursing, 20(4), 707-715.

This article examines the ability of transcultural nursing, a field that connects nursing with anthropology, to operationalize the concept of culture in order to develop culturally competent clinicians who are capable of knowing, using, and appreciating the effect of culture when providing care to the individual, group, community, or family.

Felder E (1990). The nursing cultural center, a design for cultural diversity. The ABNF Journal : Official journal of the Association of Black Nursing Faculty in Higher Education, Inc, 1(1), 7-9.

The article addresses the rationale for the development of the Nursing Cultural Center designed to effectively aid and train nurses and other health professionals to meet the challenges of cultural diversity in health care delivery. The article includes a cultural nursing center conceptual model as well as addressing five specific goals for the center, which have a general application to institutionalizing cultural competence in teaching hospitals.

Gonzalez-Calvo J, Gonzalez VM, Lorig K (1997). Cultural diversity issues in the development of valid and reliable measures of health status. Arthritis Care Research, 10(6), 448-56.

The article discusses the issues of measurement and assessment in cultural diversity research. The authors suggest that the development of instruments for use in culturally diverse settings and populations involve more then just translation. Measurements must be tested for content validity and appropriate meaning among members of the targeted group with careful attention to validity, reliability, and cross-cultural differences among cultures.

Like RC, Steiner RP, Rebel AS (1996 April). Recommended core curriculum guidelines on culturally sensitive and competent health care. Family Medicine, 28(4), 291-7.

This article outlines a proposed curriculum for family practice medical residents and students. The curriculum topics revolve around attitudes, knowledge, and skills. The article discusses the necessity of interspersing the training throughout a student’s or resident’s career.

Lister P (1999). A taxonomy for developing cultural competence. Nurse Education Today, 19(4), 313-318.

This paper proposes several elements to develop culturally competent practitioners: cultural awareness, cultural knowledge, cultural understanding, and cultural sensitivity. Cultural awareness is a state in which the student is able to describe how beliefs, values, and personal/ political power are shaped by culture, and that different cultures, subcultures and ethnicities may validate different beliefs and values. Cultural knowledge is a state in which the student begins to show familiarity with the broad differences, similarities, and inequalities in experience, beliefs, values, and practices among various groupings within society. Cultural understanding is a state in which the student recognizes the problems and issues faced by individuals and groups when their values, beliefs and practices are compromised by dominant culture. Cultural sensitivity is a state in which the student shows regard of an individual client’s beliefs, values and practices within a cultural context, and shows awareness of how their own cultural background may be influencing professional practice. Cultural competence is a state in which the student provides or facilitates care which respects the values, beliefs, and practices of the client, and which addresses the disadvantages arising from the client’s position in relation to networks of power. The authors suggest that the model could possibly be used to structure a curriculum that explores the differences among various social groupings defined according to gender, generation, lifestyle, or class as much as ethnicity.

Matherlee K, Burke N (1997 September). Cross-Cultural Competency in a Managed Care Environment. National Health Policy Forum, George Washington University, Issue Brief No. 705.

This article is a background briefing on the need for cultural competence. It outlines the different roles assumed by the federal government, such as data collection, service provision, and rules for contracting organizations, and those assumed by states, including legislation that addresses cultural competence, mostly focused on interpreter requirements. Finally, the article highlights some innovative programs that seek to develop cultural competence, including one to develop a systems approach to assessing cultural competence in health care organizations. Other programs highlighted included the following elements: interpreters, telephone triage in multiple languages, translated written materials (e.g., disclosure forms and patient education), audio-visual presentations in a range of languages, traditional healing, diversity training for staff, curricular guidelines for specialties, annual reviews of cultural competence, training physicians on the use of interpreter services, multidisciplinary outreach teams, and conducting focus groups to collect data from various ethnic groups.

Meleis AI (1996). Culturally competent scholarship: Substance and rigor. Advances in Nursing Science, 19(2), 1-16.

The author addresses the need for cultural competent scholarship in nursing, as one aspect of viewing the patient. The authors warns that “culture is only one component of what defines a human being; defining nursing clients as cultural beings may be as reductionist as defining them as biological or physiological beings. The article presents eight proposed criteria for ensuring rigor and credibility of culturally competent scholarship that can be used as guidelines for the research process and as criteria to evaluate programming. The eight criteria are: contextually, communication styles, awareness of identity, power differentials, disclosure, reciprocation, empowerment, and time.

Pasick RJ, D’Onofrio CN, Otero-Sabogal R (1996). Similarities and differences across cultures: questions to inform a third generation of health promotion research. Health Education Quarterly, 23, 142-161.

This article looks at what role culture should play in health promotion and designing interventions, specifically presenting a framework to assess cultural needs of ethnic groups. The authors identified the following similar areas of focus in several different cancer screening programs: medical care settings, location of community activities, peer education and testimonials, message content, frontline professionals of similar cultural backgrounds to whom patients could relate to, and style and language of print material.

Pernell-Arnold A (1998). Multiculturalism: Myths and miracles. Psychiatric Rehabilitation Journal, 21(3), 224-229.

The shift of the melting pot paradigm to multiculturalism is explored. The melting pot myth relates to the fact that many groups were not permitted to assimilate. A foundation is built for the connection between psychosocial rehabilitation (PSR) and multicultural approaches. PSR interventions are to be modified to respond to differences in cultural belief systems, help-seeking behaviors, and symptom development. Recommendations are made on issues and strategies that PSR programs can utilize when starting the process of becoming culturally, competent.

Philips D, Leff S, Kaniasty E, Carter M, Paret M, Conley T, Sharma M (1999). Culture, race, and ethnicity in performance measurement: A compendium of resources, version 1. The Evaluation Center at HSRI and the Center for Mental Health Services. Prepared for the Substance Abuse and Mental Health Services Administration, Depatment of Health and Human Services. Washington, DC.

This is an expansive reference on articles and definitions from multiple government agencies concerning cultural competence. It describes an approach to developing and assessing the cultural competence of the service system that evolved during the Evaluation Center at HSRI work with the NACBHD Outcomes Committee. The compendium is a compilation of resources and readings for those interested in the area of providing or evaluating culturally competent mental health care.

Puebla-Fortier J, Shaw-Taylor Y (1999). Cultural and linguistic competence standards and research agenda project. Resources for Cross Cultural Health Care. Prepared for the Center for the Advancement of Health, and the Office of Minority Health, Department of Health and Human Services. Washington, DC.

This article represents an effort by the Office of Minority Health at the Department of Health and Human Services to develop standards for culturally and linguistically appropriate services (CLAS). The article discusses the numerous difficulties in researching CLAS and its relationship to outcomes. The fourteen CLAS standards can be grouped into five categories: culturally sensitive encounters, choice of providers, language services, translated materials, and input into treatment decisions and service quality. The authors present research questions that relate the development of structure, process, and outcome measures for each of the five categories of standards. They also suggest possibly linking CLAS-related indicators to Medicaid risk adjustment, managed care reimbursement policies, and utilization related issues as possible ways to increase demand for CLAS-related research.

Rubenstein HL, O'Connor BB, Nieman LZ, Gracely EJ (1991). Introducing students to the role of folk and popular belief systems in patient care. Academic Medicine, 67(9), 566-568.

This article presents the results of an exercise carried out by the faculty at The Medical College of Pennsylvania to improve their medical students’ ability to recognize and work effectively with the health beliefs and practices of their patients. The faculty feels that physicians need to understand the pervasiveness of the nontraditional beliefs and practices of their patients and actively elicit beliefs from their patients in order to provide the best care possible. The authors instituted a four-hour session for sophomore medical students that introduced guidelines for eliciting and working with patients’ nonconventional health beliefs and practices. A pre- and post-test were administered to test the students before-and-after knowledge of (1) the ways in which a physician’s ignorance of a patient’s health beliefs and practices can adversely affect the clinical encounter; (2) the pervasiveness of nonconventional health beliefs and practices; and (3) the types of resources available for learning about these beliefs and practices. Students’ knowledge and awareness improved significantly between the pre- and post-test.

Salimbene S (1999). Cultural competence: a priority for performance improvement action. Journal of Nursing Care Quality, 13(3), 23-35.

This article outlines a model for developing cultural competence among nurses using a “cultural filter theory” of perception whereby every individual perceives the world around him or her through a filter that is created and adopted by all members of a culture. This filter determines what is said and how things are said and includes facial expressions, body language, gestures, behavior, and speech. The cultural filter is also responsible for how a person interprets his or her illness and the cause of illness. The author outlines the skills and abilities that constitute culturally competent nursing care. The stages in this model include: ethnocentricity or seeing one’s own culture as the standard measurement, the awareness and sensitivity to cultural and language differences, the ability to refrain from forming stereotypes and judgments that are based on one’s own cultural framework, the acquisition of knowledge about the cultures of patients the organization serves, and the acquisition of new skills and strategies to identify cultural differences and to know how to deal with them in a way that meets patients needs and the standards of quality care.

Smith LS (1998). Cultural competence for nurses: canonical correlation of two culture scales. Journal of Cultural Diversity, 5(4), 120-126.

This study measures the relationship among scores and sub-scores on scales measuring cultural competence among a population of registered nurses. The scales used are the Giger and Davidhizar Transcultural Assessment Model and Theory, the Cultural Self-Efficacy Scale (CSES), Cultural Attitude Scale (CAS –Modified), in addition to a knowledge base questionnaire.

Texas Department of Health. (1997) Pursuing organizational and individual cultural competency: An epistemology of the journey towards cultural competency. Prepared for the Maternal and Child Health Bureau, Health Resources Services Administration, U.S. Department of Health and Human Services.

This article explores the limits, validity, grounds, principles and standards for cultural competence. The publication explores the distinction between cultural diversity and cultural competence, as well as the myths and misconceptions related to cultural differences, which are given credence and validity. For example the authors point out the weakness of training curriculums that teach diversity as recognition of differences. A manual provides tools for defining training objectives, assessing the training environment and assessment of training methods and outcomes. The authors argue that from individual expansion comes organizational impact, which can only be measured with proper training standards and means of evaluating the impact.

Weiss CI, Minsky S (1994). Program self-assessment survey for cultural competence: manual. Prepared for the New Jersey Division of Mental Health and Hospitals.

This survey was developed by the Multicultural Services Advisory Committee to assist mental health programs in delivering culturally competent care. The survey is not aimed at assessing staff’s level of cultural competency, but rather an organization’s ability to address the needs of culturally diverse groups. The survey assesses an organization’s level of cultural competency by reviewing program policies and practices. Survey questions address organizational practices related to client diagnosis and assessment, physical characteristics of the facility, staff recruitment, and client participation. The scores are tallied to create a program profile.

Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG (1995). Language barriers in medicine in the United States. JAMA, 273(9), 724-728.

This article reviews the current status of interpreter services in the United States health care system, the clinical impact of inadequate interpretation and the legislative responses to the language needs of patients with limited English proficiency. Patients and clinicians tend to rely on one of three sub-optimal mechanisms for interpretations: (1) their own language skills, (2) the skills of family or friends, or (3) ad hoc interpreters. The DHHS Office for Civil Rights views inadequate interpretation as a form of discrimination. Language barriers impair the exchange of information from patient to physician in several ways leading to misdiagnosis and non-education. Inadequate interpretation also raises ethical problems related to informed consent. The authors offer a number of simple low cost interventions to improve access to bilingual services including: (1) multilingual signs and videos to inform patients about interpreter services; (2) bilingual phrase sheets for staff and patients; and (3) telephone interpreter access.

Performance Measures and/ or Indicators

Abt Associates (2000). Report on recommendations for measures of cultural competence for the quality improvement system for managed care. Prepared for the Health Care and Financing Administration. Washington, DC.

This report includes a set of recommendations for measures of cultural competence of managed care organizations that provide care to Medicare and Medicaid beneficiaries under contracts with HCFA or with State Medicaid agencies. The measures were developed for use in the Quality Improvement System for Managed Care (QISMC), which is a system designed to ensure that organizations providing health care services under contract protect and improve the health and satisfaction of enrolled beneficiaries. Recommendations for measures were developed from input from experts in the field of cultural competence. The Expert Panel recommended that HCFA develop measures of the following three types: 1) disparity-based measures; 2) enrollee-based measures; and 3) standards-based inventories of current practices. Disparity-based measures would identify disparities in access to care and disparity in preventive care, such as flu shots. Enrollee-based measures would assess the beneficiaries’ ability to choose congruent providers and language services. Standard-based measures would assess whether MCO had a process for identifying and addressing disparities.

The Bureau of Primary Health Care. (1999). Cultural Competence: A Journey. Health Resources and Services Administration, Bureau of Primary Health Care.

This publication summarizes the experiences of community programs affiliated with the Health Resources and Services Administration’s Bureau of Primary Health Care that provide services to culturally diverse populations. This document profiles a variety of programs such as the Sunset Park Family Health Center in New York and the Red Tail Training and Health Center in Minneapolis and chronicles their experiences in providing culturally competent service delivery, such as incorporating traditional healing, creating health facilities that are more welcoming and attractive to patients through signage and interpreters, and training culturally sensitive clinicians. The document also outlines 5 essential elements that contribute to a system’s ability to become more culturally competent, 7 domains of cultural competence and describes public health studies that demonstrate improved health outcomes resulting from providers’ ability to bridge cultural gaps between themselves and their patients.

Center for Mental Health Services (1998). Cultural competence standards in managed mental health care: Four underserved/underrepresented racial/ethnic groups. Prepared for the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. Purchase Order No. 97M047622401D.

This report addresses the need to ensure the provision of culturally competent services to underserved and underrepresented racial/ethnic groups in managed care settings. The report provides tools to guide the provision of culturally competent mental health services to four racial/ethnic populations: Hispanics, American Indians/Alaska Natives, African Americans and Asian/Pacific Islanders. Input was gathered from expert panels of consumers, mental health services providers and academic clinicians representing each of the four racial/ethnic populations. Each panel reviewed mental health research and services literature that focused on their respective population and developed a consensus around how best to achieve culturally competent managed behavioral health care for its target population. Two types of standards were developed: overall system guidelines, and clinical standards and implementation guidelines. Overall system guidelines focused on ensuring a culturally competent system of care and included standards on cultural competence planning, governance, benefit design, outreach, quality improvement, information systems, and human resource development. Clinical standards and implementation guidelines focused on ensuring culturally competence clinical practices and included: discharge planning, treatment services, and communication styles. For each standard, the report included a list of recommended performance indicators and outcomes.

Flores G (1999). A model of cultural competency in health care. Progress Notes: A Newsletter of the Massachusetts Chronic Disease Improvement Network. The Massachusetts Chronic Disease Improvement Network, 3(1), 1-3.

This article includes a model of cultural competency and tools for use by providers to become knowledgeable about the role of culture in the patient-provider interaction. The model includes 5 components; (1) “normative cultural values”, which focuses on a clinician becoming familiarized with the values within a patient’s culture; (2) “language issues”, which focuses on the use of interpreter services and promotion of bilingual skills among clinicians; (3) “folk illnesses and remedies”, which outlines a four step method for acquiring information from patients on their traditional treatment practices; (4) “patient/parent beliefs”, which instructs clinicians on identifying beliefs that impact care and approaches for communicating to patients alternatives to traditional practices; (5) “provider practices”, which focuses on tracking ethnically based disparities in screening, prescriptions and health outcomes.

Goode TD (1989. Revised 1993, 1996, 1999 and 2000) Promoting cultural and linguistic competency. self-assessment checklist for personnel providing services and support to children with special health needs and their families. Georgetown University Child Development Center- National Center for Cultural Competence (NCCC). Washington, DC.

This publication includes self-assessment tools developed by Georgetown University Child Development Center’s National Center for Cultural Competence to be used by personnel providing primary health care services. Self-assessment tools were developed for a variety of topic areas, including “values and attitudes”, “communication styles”, and the “physical environment.” Personnel are provided with a checklist that assesses how well they are demonstrating or engaging in practices that promote culturally diverse and competent services.

Cohen E, Goode TD (1999). Policy Brief 1: Rationale for cultural competence in health care. Georgetown University Child Development Center- National Center for Cultural Competence (NCCC). Washington, DC.

Goode TD, Sockalingam S, Brown M & Jones W (2000). Policy Brief 2: Linguistic competence in primary health care delivery systems: implications for policy makers. Georgetown University Child Development Center- National Center for Cultural Competence (NCCC). Washington, DC.

These policy briefs are produced by Georgetown University Child Development Center’s National Center for Cultural Competence. Policy Brief 1 and 2 include a checklist for organizations to assess how well they facilitate the development of culturally and linguistically competent primary health care policies and structures. This checklist includes items related to the incorporation of cultural competence principles into mission statements and policies regarding staff training, professional development and evaluation, and the allocation of dedicated resources to cultural competence activities.

Health Resources and Services Administration (2000). Cultural Competence Works. Awards of Excellence. “Certificates of Recognition Nominated Programs of Note” and “Certificate of Recognition.” U.S. Department of Health and Human Services. Washington, DC.

This booklet includes an abstract of the “Cultural Competence Works Awards of Excellence” presented to various health care programs. One abstract included a description of the SouthCove Community Health Center in Boston, Massachusetts (SCCHC). The abstract outlined activities conducted by the Center to ensure cultural competence, including performing client assessment and care planning in the client’s primary language, recruitment of a bilingual staff, provision of interpreter training for medical staff, and the delivery of intensive, bilingual/bicultural outreach and community health education. Other programs profiled included the South Park Family Health Center Network, which conducts yearly community needs assessment, provides new staff orientation training in cultural diversity, uses Americorp members to delivery outreach and educational activities, and has a Cultural Access Task Force focused on developing and implementing culturally competent policies. The awards were presented by the Office of Minority Health, Maternal and Child Health Bureau, and Center for Managed Care at a January 10, 2000 ceremony.

Lavizzo-Mourey R, Mackenzie ER (1996). Cultural competence: essential measurements of quality for managed care organizations. Annals of Internal Medicine, 124, 919-921.

This article addresses the need to establish guidelines of cultural competence for managed care organizations. In this article, cultural competence is defined as the demonstrated awareness and integration of the following three components: (1) “health-related beliefs and cultural values”, which incorporates the belief system and perspectives of cultural subpopulations; (2) “disease incidence and prevalence”, which requires that MCOs take into account the varying disease incidence among racial and ethnic subpopulations and collect accurate epidemiologic data to guide decisions about health education, screening and treatment programs; and (3) “treatment efficacy”, which focuses on the population-specific pharmacologic efficacy of treatment across different populations. The article provides various illustrations of these three components in managed care organizations.

Mason JL (1995). Cultural competence self-assessment questionnaire: A manual for users. Portland State University, Research and Training Center on Family Support and Children’s Mental Health. Washington State.

This report includes an instrument to access cultural competence in agencies serving children and families. The instrument includes a version for service providers and for administrative personnel. Questions included in the instrument provide ways to evaluate understanding and application of cultural competence concepts by staff. This tool is applicable across a wide range of settings.

Maternal and Child Health Bureau (2000). Maternal and child health services Title V block grant program: guidance and forms for the Title V application/annual report. U.S. Department of Health and Human Services. Washington, DC.

This document contains instructions for Title V Maternal and Child Health Block Grant grantees for submitting application and annual reports. Contained within this document are performance measures on which grantees are required to report. Specific measures related to cultural competence include health outcome measures and developmental health status indicator measures.

Maternal and Child Health Bureau (1990). State children with special health care needs Title V directory workshop: Improving state services for culturally diverse populations. Prepared for Division of Services for Children with Special Healthcare Needs, Maternal and Child Health Bureau, Health Resources and Service Administration, and Department of Health and Human Services. Washington, DC.

This report summarizes proceedings from a Work Group convened during a May, 1990 conference entitled “Cultural Perspectives in Service Delivery for Children and Families with Special Needs.” The conference was convened by the Maternal and Child Health Bureau to assist states in assessing and improving delivery of services to culturally diverse populations of children with special needs and their families. The Work Group developed specific guidelines, strategies, policies and activities that could be undertaken by states to accomplish the goal of culturally competent health care delivery. The Work Group identified critical components of culturally competent programs and outlined a set of objectives to assist States in achieving these components. 

Munoz RH, Sanchez AM. Developing culturally competent systems of care for state mental health services. Prepared for Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. Washington, DC.

This report examines the impact of culture on mental health, strategies for instituting cultural competency into mental health care, and a plan of action for developing a culturally competent system of care. The report provides a framework of a culturally competent system of care and outlines essential components of that system. Also included is the experience of five states that apply culturally competent principles in real-life settings. States recount challenges and difficulties in implementing