Setting the Agenda for Research on Cultural Competence in Health Care (continued)

Highlights of the Research Agendas

The successes and limitations of the existing impact literature on cultural competence point to substantial opportunities for future research in each of the identified categories. Using both descriptive and quantitative approaches, this research can further illuminate the details of cultural competence interventions as well as specific impacts on health care delivery outcomes.

The major task of this project was to propose future research directions in the area of cultural competence and health care delivery and health outcomes. By analyzing the literature, the project team was able to identify areas where the current research was weak or lacking, and suggest areas and questions for further exploration. These efforts were buttressed by the discussions and recommendations of the RAC, both during the April 2001 RAC meeting and in subsequent reviews of the research agenda drafts.

The major product of this endeavor is the group of research agendas found at http://www.omhrc.gov. Each research agenda contains a definition of the category, a brief synthesis of findings from the literature, key research questions, and a discussion of methodological and policy considerations influencing future research for that area.

The research agendas reflect that some of the topic areas were backed by a greater body of literature and/or generated more interest from RAC members. The extensive agenda developed for the language assistance interventions category mirrors its prominence among both health care providers and policymakers. It is also the agenda best supported by previous research related to outcomes. Additional topics generating significant interest included cultural competence education and training, and racial, ethnic and linguistic concordance. The topic of organizational supports generated a broad list of questions, although the majority of these focused on their effect on the processes of health care delivery and not on health outcomes.

It is interesting to note that as stakeholder interest and investment in implementing certain interventions increases (e.g., interpreter services, hiring for diversity, cultural competence training), so too does the demand for concrete linkages between an intervention and outcomes, especially cost-related benefits.

Conversely, there are many providers who are willing to undertake these interventions without "proof of value," perhaps simply due to consumer demand for such interventions or because the face value of the intervention is obvious. Many RAC members pointed out that, methodological and funding challenges aside, the importance of outcomes research on cultural competence interventions should not be overstated, given that many cultural competence interventions have already been implemented despite the lack of rigorously conducted, definitive outcomes studies.

The following highlights of the Cultural Competence Research Agenda are organized into three groups of cultural competence interventions:

• Category A: Culturally Sensitive Interventions.
• Category B: Language Assistance.
• Category C: Organizational Supports for Cultural Competence.

A complete list of research questions can be found in Part 2 of the full report.

Category A: Culturally Sensitive Interventions

Cultural Competence Education and Training

Among the activities listed under Category A, cultural competence education and training generates considerable interest among providers, educators, and policymakers for its potential impact on improving the patient- provider relationship when cultural differences exist. While the descriptive literature on this topic is extensive, studies that examine the impact of training on either trainees and patients is more limited. Some connections are made with increases in levels of cultural knowledge, attitudes and awareness, and improvements in communication skills among trainees. Few studies examined the impact of training on health care delivery, patient behavior change, or health outcomes. The topic and the literature, however, were sufficient to inspire a substantial number of future research questions. These include questions that seek to better understand and define the intervention related to:

• Trainees and motivation (e.g., what incentives are sufficient to motivate clinicians to undertake cultural competence training—improved patient-provider relationship, improved health outcomes, financial rewards?)
• Content of training (e.g., what competencies and basic skills produce behavioral changes by trainees and improvement in health and health care delivery outcomes?)
• Form of training (e.g., which educational delivery techniques are most effective at changing trainee behavior?)

Another category of questions seeks to measure the impact of training on both providers and patients. These include questions on:

• Achieving behavioral changes among trainees (e.g., what degree of knowledge or awareness translates into action? Is there a dose-response relationship for certain training interventions, and what is the minimum intervention that will result in acceptable outcomes?)
• Measuring impact on health care delivery and health outcomes (e.g., do patients of providers who have received training show improvements in satisfaction, adherence to treatment recommendations, keeping recommended follow-up visits, etc.?)

Racial, Ethnic, and Linguistic Concordance

The topic of racial, ethnic and linguistic concordance among providers and patients has already generated considerable research interest. The literature suggests that some patients from multicultural groups prefer to seek care from providers of their own race, ethnicity, or language group, and that such concordance appeared to have a positive impact on appropriate service utilization, treatment participation, and receipt of some services. However, the literature on the effects of positive outcomes in utilization was not shown to translate into improvements in health outcomes. Many health care organizations and policymakers have pursued diversification of the workforce as a way of increasing patient-provider concordance, although others are skeptical, given the demographic difficulties of achieving this goal across-the-board. Nevertheless, ongoing research in this area can also be of considerable value for what it illuminates about crosscultural health care encounters. Key research questions focus on:

• Concordance and the clinical encounter (e.g., what can we learn from concordant encounters about factors that could be emulated in non-concordant encounters?).
• Patient-related health care delivery and health outcomes (e.g., does concordance affect patient/consumer comprehension, satisfaction, appropriate utilization of services, adherence to treatment, perceived health status and/or quality of life measures?).
• Clinician-related outcomes (e.g., does concordance have an effect on clinician behavior/perceptions? Measures could include time spent with patients/consumers, number of treatment options discussed, level of interaction, number of questions the patient is allowed to ask, negotiation of treatment options, clinician perceptions of effectiveness of his/her efforts.).
• The impact of concordance on organizations (e.g., does the overall level of staff awareness and sensitivity to cultural issues improve when there is diversity throughout the organization?).

Community Health Workers and Culturally Competent Health Promotion

Both these topics have already been extensively researched, although not necessarily with a specific focus on the effect of the culturally competent aspect of the interventions. Studies suggest linkages between the intervention and increases in health-care-related knowledge, self-care practices, screening rates, and decreases in risk behaviors. Both types of interventions could benefit from further research in the following areas:

• What is the impact on knowledge, behavioral change, and/or health outcomes of community health workers (CHW) and culturally competent health promotion (CCHP) programs versus standard interventions? Versus no intervention?
• Is there a significant improvement in health care delivery and/or health outcomes when the intervention is highly tailored to subgroups and subcultures as opposed to generalized culturally competent health promotion programs?
• Which elements of the culturally sensitive methods utilized by CHW and CCHP programs improve access, quality and utilization of services?

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Category B: Language Assistance

Language Barriers, Bilingual Services, Oral Interpretation, and Translated Written Materials

The literature on the impact of language barriers and language assistance interventions is both substantial and promising with respect to outcomes. Studies show that language barriers have a demonstrable negative impact on communication, satisfaction, and appropriate health care utilization. A growing body of literature suggests that language assistance interventions such as oral interpretation can have a positive effect on patient satisfaction and comprehension, and improvements on health care delivery measures such as increases in the amount of time spent with patients, reduction in diagnostic testing disparities among English-speaking patients versus limited English proficient (LEP) patients, higher clinic return rates, and increases in primary care services utilization.

The research agenda on this topic is divided into four areas around which to structure future research efforts on language assistance:

• Impact research (e.g., what is the impact of untrained interpreters versus trained interpreters on different outcomes?).
• Cost-related research (e.g., what are the cost-benefits of different types of language assistance services and of not providing interpreter services?).
• Organizational research (e.g., what are the human resource management considerations, including cost, involved in using bilingual staff who have other responsibilities as ad hoc interpreters?).
• Translation and miscellaneous topics (e.g., do translated prescription instructions lead to fewer patient medication errors and/or better adherence?).

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Category C: Organizational Supports for Cultural Competence

The research agenda identifies eight types of organizational supports for cultural competence. These are primarily management activities not expected to have a direct impact on health outcomes, but intended to improve health care delivery to culturally diverse populations.

To date, both descriptive and process-related outcomes research on these activities is very limited. However, a number of research questions were identified that would better define these interventions and investigate potential links between them and improved organizational efficiency. They include research related to:

• Management, policy and implementation strategies to institutionalize cultural competence activities (e.g., does the existence of explicit plans and strategies for the implementation of cultural competence interventions facilitate and improve the delivery of those services over an ad hoc approach?).
• Community involvement in CLAS program planning, design, implementation, governance, training, and research (e.g., does having ethnic community advisory committees or other mechanisms of community input have a measurable and beneficial effect on the successful implementation and acceptance of plans, policies, and programs of culturally competent interventions, either at the organizational or programmatic level?).
• Design and use of surveys and profile instruments to plan for services and measure satisfaction, quality of services (e.g., what level of community input, data gathering and testing is necessary to develop culturally valid tools for information gathering, as many health care organizations have neither the time nor resources to engage in complex survey development processes for the purposes of service planning and design? Are there model instruments or templates that can be easily adapted? What are the benefits of the process of involving the community in survey design, above and beyond implementing an acceptable tool?).
• Cultural competence self assessments (e.g., what impact does the implementation of organizational self-assessments have on motivating improvements on cultural competence within the organization, and overall organizational strategic planning?).
• Ethnic data collection/community profiles (e.g., does the easy availability of race/ethnicity/language data improve the timely delivery of culturally competent services, such as insuring an interpreter is present for appointments, sending materials in the appropriate language, or assigning enrollees to a concordant clinician if the enrollee doesn't select a clinician?).

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Summary of Methodological and Practical Considerations

While there is a high level of interest in the results of research on cultural competence interventions, the RAC identified several methodological challenges to conducting such research. These include lack of:

• Standardized definitions of the interventions.
• Standardized evaluative measures.
• Culturally competent instruments.
• Secondary data sources with uniform racial, ethnic, and language data.

An additional challenge is the large sample size that is required to prove that cultural competence interventions are more effective than similar interventions that are not designed to be culturally competent.

The RAC also identified various factors that impede the funding and publication of cultural competence research. RAC members thought that funders and journal reviewers tended to lack familiarity with the impact of language and culture on health care delivery and viewed cultural competence research as marginal and/or high risk. This was thought to make some funders unwilling to expend the amounts of money necessary to show linkages between cultural competence interventions and health outcomes, and journals unwilling to accept manuscripts. Researchers, in turn, may therefore consider cultural competence studies to be a high risk undertaking.

These challenges, as well as the RAC's suggestions for addressing them, are discussed in further detail in Part 3 of the full report.

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References

 Brach, C., and Fraser, I. (2000). Can cultural competency reduce racial and ethnic disparities? A review and conceptual model. Med Care Res Rev 57(Suppl 1):181-217.

 U.S. Department of Health and Human Services Office of the Secretary. (2000). National standards on culturally and linguistically appropriate services (CLAS) in health care. Federal Register 65(247):80865-79.

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