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Agency for Healthcare Research Quality

Setting the Agenda for Research on Cultural Competence in Health Care

Introduction and Key Findings

Health care providers take many approaches to bridge barriers to communication that stem from racial, ethnic, cultural, and linguistic differences. "Cultural competence" encompasses both interpersonal and organizational interventions and strategies for overcoming those differences.

This document examines how cultural competence affects health care delivery and health outcomes, and it is sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Office of Minority Health (OMH). Part 1 of the report, which is presented here, comprises the introduction and key findings.

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Print copies of the full report (Publication No. 474) can be ordered from the Office of Minority Health Resource Center (1-800-444-6472).


   Context of Diversity and Cultural Competence in Health Care
   The CLAS Standards and Cultural Competence Research Agenda Projects
   Objectives of Cultural Competence Research
Overview of the Cultural Competence Research Agenda Project
   Project Goals and Objectives
   Project Methodology
   Highlights of Literature Review Findings
   Highlights of the Research Agendas
   Summary of Methodological and Practical Considerations


The authors of this report wish to acknowledge the Office of Minority Health of the U.S. Department of Health and Human Services (HHS) and AHRQ for their significant interest in, and funding of, work on cultural competence. We especially appreciate the support of the two government project officers, Guadalupe Pacheco (OMH) and Cindy Brach (AHRQ).

We also thank members of the project's Research Advisory Committee for their dedication to research, practice, and policymaking in the area of cultural competence, and for their time and effort to lend expertise to the crafting of this research agenda. Gwendolyn Sanders-Conyers of IQ Solutions deserves special mention for her expert and professional handling of all advisory committee meeting arrangements.

We salute the many other health care providers and researchers who have laid the foundation for this project through their groundbreaking work in developing practice models and investigating the effects of cultural competence interventions. We appreciate the opportunity to acknowledge their work in this report, and commend their experience to funders of both research and culturally competent services.

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Context of Diversity and Cultural Competence in Health Care

The steadily increasing diversity of the United States affects health care providers and institutions, from small rural towns to large urban centers. The impact of this diversity means that every day, health care providers encounter, and must learn to manage, complex differences in communication styles, attitudes, expectations, and world views. Decades of literature from the social and clinical sciences have documented the details, effects, and potential remedies to issues that arise when different cultures encounter each other.

Health care providers take many different approaches to bridge barriers to communication and understanding that stem from racial, ethnic, cultural and linguistic differences. In recent years, the notion of "cultural competence" has come to encompass both interpersonal and organizational interventions and strategies that seek to facilitate achievement of clinical and public health goals when those differences come into play.

There have been many attempts to describe and quantify cultural competence in health care. These include:

  • Formal definitions.
  • Model programs.
  • Laws, regulations, and standards.
  • Performance measures and other evaluative criteria.

But what does cultural competence actually accomplish? Does it make a difference to patients and to health care delivery and health outcomes? This project looks at the question of what impact cultural competence interventions have on the delivery of health care and health outcomes, and investigates the opportunities and barriers that affect how further research in this area might be conducted.

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The CLAS Standards and Cultural Competence Research Agenda Projects

This document is the final report for the Cultural Competence Research Agenda project, sponsored by OMH and AHRQ to examine how cultural competence affects health care delivery and health outcomes. It completes a process begun in 1998 with the OMH-sponsored development of national standards for culturally and linguistically appropriate services (CLAS) in health care. The CLAS standards were published in the Federal Register in December 2000 (U.S. Department of Health and Human Services Office of the Secretary, 2000). The standards have become the basis for subsequent government and private sector activities to define, implement, and evaluate cultural competence activities among health care providers.

The CLAS standards were initially derived from an analysis of current practice and policy on cultural competence, and further shaped by the input and expertise of health care providers, policymakers, researchers, advocates, and consumers. The 14 standards are organized by themes:

  • Culturally Competent Care (standards 1-3).
  • Language Access Services (standards 4-7).
  • Organizational Supports for Cultural Competence (standards 8-14).

Standards 1-7 address interventions that have the most direct impact on clinical care; and standards 8-14 address organizational structures, policies and processes that support the implementation of standards 1-7.

The CLAS standards were developed to provide a common understanding and consistent definitions of culturally and linguistically appropriate services in health care. They are intended to offer a broad and practical framework for the implementation of services and organizational structures that can help health care providers be responsive to the cultural and linguistic issues presented by diverse populations. While aimed primarily at health care organizations, individual clinicians are also encouraged to use the standards to make their practices more culturally and linguistically accessible. The standards are intended to be inclusive of all cultures and not limited to any particular population group or sets of groups; however, they are especially designed to address the needs of racial, ethnic, and linguistic population groups that experience unequal access to health services.

It was the understanding of the CLAS standards sponsors that wide adoption of cultural competence activities, as described in the standards, would ideally be supported by research that links the performance of those activities, improved health care delivery and better health outcomes. Many health care providers and policymakers have fundamental questions about the intrinsic and relative value of different cultural competence methods and programs. These questions may relate to:

  • Access and outcomes (which interventions increase access for culturally and linguistically diverse populations to health care services and/or improve their health outcomes?)
  • Quality and reduction in errors (which interventions increase the provision of appropriate care to and/or reduce the incidence of medical errors among diverse populations?)
  • Cost (which interventions are cost effective—e.g., reduce diagnostic testing and emergency room use or increase preventive services lowering future health costs?)
  • Comparative analyses (which approaches or interventions work best under which circumstances?)

OMH and AHRQ sponsored the development of a health services research agenda on cultural competence in health care to promote the creation of an evidence base that would address these questions.

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Objectives of Cultural Competence Research

How best to pursue further research on cultural competence interventions depends greatly on the kinds of questions stakeholders want to answer. Different stakeholders may have different informational needs, and these needs, while convergent at times, may vary in the order of importance from one stakeholder group to the next.

For example, basic definitions and parameters are needed for every category of cultural competence intervention. These definitions are critical, not only to support basic program design and evaluation, but also to facilitate the evaluation of additional research on outcomes where standard definitions are necessary for comparability of results. Research required to produce these definitions and identify the standard elements of interventions is not methodologically difficult, but some stakeholders may perceive this work as less important because it does not directly address outcomes that are more important to them. It is likely that this type of research will be of greatest interest to those attempting to standardize interventions for the purposes of quality control; regulators and standard setters; individuals who design and implement cultural competence interventions; and investigators who need standard definitions for conducting cultural competence research.

Stakeholders who are primarily interested in the success of the clinical encounter (e.g., patients, families, and clinical staff), may have more interest in the impact that cultural competence interventions have on what are often called intermediary outcomes (e.g., comprehension, satisfaction, adherence to medication and lifestyle recommendations, appropriate utilization). Those who pay for health care are especially interested in how cultural competence interventions affect utilization of services. Because of the large number of potentially confounding variables, it is very difficult to show a direct link between a cultural competence intervention and health status improvements and/or cost savings. It may be, however, possible to link together a number of intermediary outcomes that contribute to health status improvements and/or cost savings. For example:

  • CLAS lead to better communication (measured by comprehension, satisfaction, etc.).
  • Better communication leads to better adherence to medications and lifestyle changes.
  • Better adherence to medications and lifestyle changes leads to improved health status.
  • Improved health status leads to lower undesirable health care use (such as Emergency Department visits and hospitalization).

To integrate multiple perspectives, the project team applied a common set of outcomes research questions to cultural competence interventions to develop a research agenda that cuts across stakeholders' interests.

Did the intervention do what it was supposed to do?

For example:

  • Did provider knowledge/awareness improve after training?
  • Did patients in need of culturally competent services receive them?
  • Were written translations understandable?

Did the intervention affect processes of care?

These might include:

  • Provider behavior modification.
  • Patient comprehension, participation in communication, treatment negotiation.
  • Time spent with the physician.
  • Diagnostic accuracy.

Did the intervention improve access to services and/or appropriate utilization of services?

Measures might include:

  • Receipt of diagnostic tests, appropriate medications, preventive/specialist services.
  • Number of admissions.
  • Hospital days, length of stay, bounce-back/recidivism.
  • Preventable hospitalization.
  • Inappropriate usage of services (e.g., ED).
  • Most-to-least restrictive setting progression.
  • Error reduction and/or patient safety.
  • Medication errors, inappropriate treatment, unnecessary procedures.

Did the intervention affect patient satisfaction and health behaviors?

Other measures might include:

  • Patient trust.
  • Acceptance of preventive services.
  • Adherence to medications, appointments, lifestyle change recommendations.
  • Patient loyalty.
  • Health seeking behavior.

Did the intervention affect patient health outcomes?

These might include:

  • Better control of chronic disease symptoms.
  • Improved health status:
    • Self-report.
    • Established medical outcomes.
  • Quality of life.
  • Population-based/community-level indicators:
    • Morbidity, mortality.
    • Prevalence/incidence of disease.
    • Level of acuity.

Did the efficiency and cost-effectiveness of health care delivery change?

For example:

  • Does it take more time to use a trained vs. untrained interpreter?
  • Did the intervention reduce inappropriate care, resulting in cost savings?
  • Did the intervention increase preventive care/early intervention that reduced treatment costs?

Contrary to popular perception, research in many of these areas has begun and is of growing interest to the health services research community. Much of this work looks at the impact of attempting to improve communication between clinicians and patients when cultural or linguistic factors are involved. However, further work is needed to raise awareness about the existing evidence base on cultural competence interventions, and to promote continued research in this area. Advancing a cultural competence research agenda involves many tasks. Specific research questions need to be identified. Funding must be made available for this research. A cadre of interested researchers needs to be cultivated and networked. Data sets need to be identified and analyzed. Most importantly, the results of research must be made widely available to practitioners, policymakers, and other researchers.

Another important task, given the limited resources available for research on cultural competence interventions, is improved information-sharing about research projects to share research instruments and methods, promote collaboration, avoid duplication, and maximize limited funding. While no single study is definitive and additional research is always needed to confirm the validity of initial studies, better awareness of, and coordination of efforts, could advance critical areas of research more efficiently.

Recently published studies reinforce the intuition:

  • A lack of attention to cultural issues leads to less than optimal health care.
  • Addressing these concerns or using certain cultural competence interventions leads to improved outcomes.

This research does not exist for every population or every type of cultural competence intervention—most of it is concentrated on the impact of language or communication barriers—but it is sufficient to suggest that additional work in this area is warranted.

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Overview of the Cultural Competence Research Agenda Project

Project Goals and Objectives

The main goal of the Cultural Competence Research Agenda Project is to produce and disseminate to key stakeholders a research agenda on the relationship between cultural competence interventions and health care delivery and health outcomes. This goal has been accomplished through completion of the following tasks:

  • Developing a working consensus on the parameters and specifics of cultural competence interventions for the purposes of conducting health care delivery and health outcomes research.
  • Collecting, reviewing and making available to the public abstracts of published, unpublished, and in-progress research on cultural competence.
  • Identifying key research questions on cultural competence that have been the subject of research, and describing the strengths and limitations of this research.
  • Identifying key research questions on cultural competence that have yet to be studied.
  • Identifying issues related to study design, potential data sources and study sites.
  • Identifying larger contextual issues related to cultural competence research: how to interest potential researchers, linking content experts with research experts, researcher collaboration/ networking, funding for research, publication, and how to involve and gain the support of research stakeholders (providers, policymakers, consumers) in the identification and utilization of research findings.

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Project Methodology

Preparing the cultural competence research agendas involved a multi-step process:

  1. Conducting a literature review.
  2. Convening a Research Advisory Committee (RAC).
  3. Drafting, soliciting comments on, and revising the research agenda.

The project was guided by the following definition of cultural competence used in the CLAS Standards Report (U.S. Department of Health and Human Services Office of the Secretary, 2000).

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

Conduct Literature Review

A multi-source, first-run literature search was conducted to identify research that used empirical analysis to measure the impact of culturally and linguistically competent interventions on outcomes, specifically issues related to access, utilization and health status. A substantial number of published studies in this area document racial and ethnic health disparities, present arguments for integrating culturally competent interventions, or describe models and methodologies. However, the goal of this search was to quantify and analyze the research base where the primary focus is the measurement of the impact of the intervention.

The project team developed a key word template consisting of approximately 177 terms and word combinations using as a framework the cultural competence interventions listed in the CLAS Standards Report (U.S. Department of Health and Human Services Office of the Secretary, 2000), supplemented by interventions cataloged by Brach and Fraser (2000). The CLAS Standards Report describes 14 actions that can be taken by health care organizations to improve cultural and linguistic competency; Brach and Fraser sets out nine interventions that could be used to reduce racial and ethnic health disparities.

The template was applied to major literature databases, including MEDLINE® (1966-2001), CINAHL® (1982-2001), PsycINFO (1987-2001) and Sociological Abstracts (SOCA)/Sociofile (SOCIO) (1963-2001). In an attempt to identify additional research, publications, or projects relating to cultural and linguistic competence, a Web site search was also conducted. This entailed the review of 38 private foundations currently funding public health and health services initiatives, 58 health policy organizations and associations, and the government Web sites of all Federal health and human services agencies and bureaus. Information about unpublished studies and research in progress was gleaned from these sources and also from the project Research Advisory Committee and other individuals interested in research on cultural competence.

Convene Research Advisory Committee

A Research Advisory Committee (RAC) of key researchers, policymakers and health care providers was convened to review the literature and make recommendations for a research agenda to pursue work in this area. The 30-member RAC met in Washington, DC, in April 2001 for a 2 1/2-day meeting to review the analysis of the literature on cultural competence and outcomes. The RAC was divided into three groups according to interest area and expertise to develop research questions for their topic areas and discuss methodological concerns related to conducting research in that area. The group also met as a whole to discuss overarching issues related to the definitions, study design, and funding/publication challenges of cultural competence research, which are described in Part 3 of the full report.

Draft, Solicit Comments on, and Revise Research Agenda

Drawing on the RAC's recommendations and findings from the literature review, the project team prepared individual research agendas for each of the main topic areas. The draft agendas were sent to RAC members for comment. Public comment was solicited by posting the draft agendas on the DiversityRx Web site ( and circulating them to the National Council on Interpretation in Health Care LISTSERV®.

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Highlights of Literature Review Findings

The literature review revealed a considerable amount of descriptive literature on each of the interventions. Although this information does not present a scientifically based argument for the use of most of these interventions, it supports the initiation and continuation of research in this area. Additionally, the value of descriptive literature should not be overlooked in the research development process. Descriptive information can provide the foundation for model duplication, identification of best practices, meta-analysis, identification of standard measures and instruments, hypothesis generation and further empirical research.

This search uncovered only a limited number of published studies for each of the interventions that employed rigorous research methodologies, and these are described in more detail in the literature analyses and matrices in Appendix 2 and the abstracts in Appendix 4. Some of the well-established, non-cultural competence specific-approaches, such as health promotion and education, have, through an evolutionary process, incorporated certain elements that enhance outreach efforts and service delivery to multicultural communities. In these instances, the descriptive and empirical research base was substantially larger than some of the more recently recognized interventions such as cultural competence training.

Although limited in scope and depth, the body of existing empirical studies does suggest that several of the proposed interventions have the potential to affect health care delivery and health outcomes. Culturally sensitive interventions such as cultural competence training and racial and ethnic concordance have shown improvements in subjective, self-assessed measures of provider knowledge and patient satisfaction. Health promotion and education programs that utilize interpreters, community health workers, translated materials and other culturally sensitive approaches reported increases in intake, program completion, and knowledge.

Studies examining the impact of community health workers and traditional healers were almost non-existent compared to the large volume of descriptive literature detailing the use of these practices. Studies examining the impact of linguistic and communication interventions on outcomes were found to have different degrees of effectiveness on patient satisfaction and health services utilization. No literature was identified that specifically examined both the processes and outcomes of organizational accommodations for cultural and linguistic competence.

In summary, the literature reveals promising trends in outcomes-related research that should be further explored. Certain cultural competence interventions appear to affect health services utilization, satisfaction, and increases in knowledge, although subsequent impacts on provider or patient behavior and/or health outcomes were not explored. Some studies that measured outcomes for specific interventions revealed contradictory and inconclusive results, due to significant variations in definitions, study design or approach. Their findings cannot be easily generalized, further supporting the need for additional research. Clearly, the results of this literature search demonstrate an opportunity to further build an evidence base linking cultural competent interventions to specific impacts on outcomes.

Additionally, future literature reviews that search for specific outcomes may result in a more comprehensive set of literature findings. However, this would require significantly more searches and review time and a clear definition of outcomes being sought. There are many outcomes that could be examined such as health services utilization, satisfaction, compliance, health knowledge, communication, improved health outcomes, etc. However, it may be very difficult to identify and link specific interventions and approaches to these improvements. It may also be difficult to link interventions of integrated culturally sensitive approaches to positive outcomes if those interventions were not the main focus of the study.

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