Review of Current Cultural and Linguistic Diversity
and Cultural Competence Reporting Requirements,
Minimum Standards and Benchmarks for Victoria
Health Services Project
Literature Review
Published by the Statewide Quality Branch
Victorian Government Department of Health
Melbourne Victoria
August 2009
© Copyright State of Victoria, Department of Health, 2009
The publication is copyright. No part may be reproduced by any process except in
accordance with the provisions of the Copyright Act 1968.
Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.
This document can be downloaded from the Department of Human Services web site
at:www.dhs.vic.gov.au
Acknowledgements
This report was written by the Institute for Community, Ethnicity and Policy
Alternatives, Victoria University
Edited by: Patrice Higgins
Funded by: The Department of Human Services
The text represents the views of the authors and may not represent the views of the
State Government.
2
CONTENTS
EXECUTIVE SUMMARY .............................................................. 5
1. INTRODUCTION .................................................................... 7
2. LITERATURE REVIEW METHODS ........................................... 8
3. DEFINING CULTURE, CULTURAL COMPETENCE AND
CULTURAL DIVERSITY .............................................................. 9
4. RELEVANCE OF CULTURAL COMPETENCE TO HEALTH AND
WELLBEING ............................................................................ 11
5. MODELS OF CULTURAL COMPETENCE.................................. 13
5.1 Discussion and Analysis: How do the models guide intervention? ......... 17
6. CULTURE AS A FACTOR IN SAFETY AND RISK MANAGEMENT
IN HEALTH SYSTEMS .............................................................. 20
7. GOVERNMENT POLICY AND REPORTING FRAMEWORKS FOR
CULTURAL DIVERSITY ............................................................ 28
7.1. Mapping Cultural Diversity Policy, Planning and Reporting Arrangements
for Cultural Diversity ............................................................................ 28
Health Service Cultural Diversity Plan (HSCDP) ....................................... 30
7.2 Discussion ..................................................................................... 32
7.3 Selected Commonwealth and State Policies and Reporting Frameworks 35
8. STANDARDS OF CULTURAL COMPETENCE FOR HEALTH
SERVICES ............................................................................... 40
8.1 Australian Standards ...................................................................... 41
8.2 International standards................................................................... 45
8.3 Discussion ..................................................................................... 46
9. INDICATORS AND ASSESSMENT TOOLS .............................. 49
10. TOWARDS A FRAMEWORK OF CULTURAL COMPETENCE
ASSESSMENT .......................................................................... 55
11. CONCLUSION .................................................................... 58
REFERENCES ........................................................................... 60
RESOURCES ............................................................................ 68
Appendix 1 ......................................................................................... 68
Minimum Reporting Requirements Under HSCDP .................................. 68
Appendix 2 ......................................................................................... 70
Core Strategies of the Cultural diversity plan for Victoria’s specialist mental
health services 2006–2010 ................................................................ 70
Appendix 3 ......................................................................................... 71
Culturally and Linguistically Appropriate Services and Standards (USA) ... 71
Appendix 4 ......................................................................................... 73
3
Lewin Group Cultural Competence Domains (2002) .............................. 73
Appendix 5 ......................................................................................... 75
Cultural Competence Assessment Tools ............................................... 75
Mental Health Assessment Tools ......................................................... 84
4
EXECUTIVE SUMMARY
This literature review was prepared by the Institute for Community, Ethnicity and
Policy Alternative (ICEPA), Victoria University. The review was commissioned by the
Statewide Quality Branch of the Victorian Department of Human Services (the
department). Its main aim was to conduct a review of cultural and linguistic diversity
and cultural competence reporting requirements, minimum standards and
benchmarks for health services incorporating:



Mapping and analysis of current department cultural diversity and cultural
competence reporting requirements for Victorian health services from department
and health service perspectives;
Mapping and analysis of current national and international literature on cultural
diversity and cultural competence focusing on reporting requirements, minimum
standards and benchmarks for health services; and
Examination and identification of key interventions and their enablers for cultural
diversity and cultural competence together with evidence of the efficacy of these
interventions within health services.
A systematic approach was adopted to identify, critically evaluate and synthesise
relevant information from international, Commonwealth and state documents,
academic databases, refereed journal articles, government policy statements and
government and non-profit organisation publications. The review included documents
available from on-line sources, reports, conference papers, keynote speeches,
discussion papers and websites which are commonly referred to as grey literature.
Various definitions of culture, diversity, cultural diversity and cultural competence
arose throughout the literature. Through analysis of these definitions, it was
determined that there is no conclusive and agreed upon definition of these concepts.
Cultural competence in healthcare has emerged partially as a strategy to address
racial and ethnic disparities that may lead to health inequalities. Several studies,
both Australian and international, have documented the benefits of a culturally
competent health care system to potentially reduce health disparities among
populations from culturally and linguistically diverse (CALD) backgrounds. However,
there is little conclusive evidence on cultural competence framework/s and their
efficacy in reducing health inequalities.
Several studies document that failure to consider a patient’s cultural and linguistic
issues can present risk/s to health services and their clients, especially in terms of
preventable adverse events in patients of minority backgrounds. Some studies
suggested that in order to minimise risks, health care organisations needed to
integrate cultural competence into their internal quality improvement activities.
In the review of policy and reporting frameworks for cultural diversity it was noted
that there are many complex reporting and planning arrangements within the
Department of Human Services. A review on standards of cultural competence found
a lack of national standards in relation to the provision of culturally and linguistically
appropriate health services. The National Quality Framework suggested that a
standardised core set of performance measures based on cross-cultural quality
issues that is broadly applicable across all healthcare settings should be adopted.
5
A number of cultural competence assessment frameworks were reviewed in the
context of health care services and it was found that models of cultural competence
needs to be embedded within organisational processes. From the existing models
and strategies reviewed in the literature, some key headings are provided to assist in
developing a range of agency specific measures and indicators.
An example from the Migrant-friendly Hospitals Project highlights the initiative of the
European Union in putting migrant-friendly, culturally competent health care and
health promotion higher on the European health policy agenda, and in supporting
other hospitals through compiling practical knowledge and instruments. The
recommendations from this project were launched as the ‘Amsterdam Declaration
towards Migrant Friendly Hospitals in an ethno-culturally diverse Europe’. A core
recommendation from this declaration is the need to define what cultural
competence means; and at a service level to:


‘find consensus on criteria for migrant-friendliness, cultural competence and
diversity competence that are adapted to their specific situation; and
to integrate them into professional standards and to enforce their realisation in
everyday practice’.
The review concludes that there is much written on cultural diversity and cultural
competence in healthcare. Research indicates there are benefits of integrating
cultural competence into health care delivery systems. Effective outcomes of
integrating cultural competence into health services can be achieved by developing
and implementing a customised holistic approach and embedding it into the
organisational context with an ongoing monitoring and review system.
6
1. INTRODUCTION
The Department of Human Services (the department) has commissioned Victoria
University’s Institute for Community, Ethnicity and Policy Alternatives (ICEPA) to
develop and implement a project plan incorporating a review of Cultural and
Linguistic Diversity (CALD) and cultural competence reporting requirements,
minimum standards and benchmarks for health services. The key objectives of the
project are:
1. Mapping and analysis of current department cultural diversity and cultural
competence reporting requirements for Victorian health services, from
department and health service perspectives.
2. Mapping and analysis of current national and international literature on cultural
diversity and cultural competence focusing on reporting requirements, minimum
standards and benchmarks for health services.
3. Examination and identification of key interventions and their enablers for cultural
diversity and cultural competence, together with evidence of the efficacy of these
interventions within health services.
4. Using the results of Objectives 1-3, develop a practical strategic framework for
the development of appropriate standards for cultural diversity and cultural
competence interventions for Victorian health services and make
recommendations as to a minimum set of standards.
5. Test the strategic framework and recommended minimum set of standards with
health services and members of Cultural Diversity Committees (CDCs) at one
statewide workshop and report on project findings to the Statewide Quality
Branch.
This literature review component of the project report incorporates the first three
objectives and forms the first step in the Review of Current Cultural and Linguistic
Diversity and Cultural Competence Reporting Requirements, Minimum Standards and
Benchmarks for Victoria Health Services Project.
The review has two overlapping and interrelated purposes:


The first is to synthesize and examine the current understanding of cultural and
linguistic diversity and cultural competence; measurement of cultural competence
amongst health care personnel; documentation of organisational frameworks that
support cultural competence, and the establishment of cultural competence
reporting methodology.
The second purpose of this literature review is to generate a framework to inform
decisions about the scope, content, and mechanisms to enhance any existing
frameworks for culturally competent health care services.
7
2. LITERATURE REVIEW METHODS
Approach: This literature review adopts a systematic approach to identify, critically
evaluate and synthesise relevant information.
Search Strategy: A search of international, Commonwealth and state documents
was conducted using various combinations of key words and phrases for example
cultural diversity and cultural competence; reporting requirements and minimum
standards, safety and culture in health care, measurement of cultural
responsiveness, racism and safety and risk in health care settings and benchmarks
for health services.
A further search was carried out using academic databases for example Medline,
CINAHL, and a range of ‘on line’ full text journals. The types of references used
include refereed journal articles, government policy statements as well as
government and non-profit organisation publications. Documents commonly referred
to as grey literature available from on-line sources, reports, conference papers, key
note speeches, discussion papers and websites are also included. The review notes
that while there is a plethora of articles on ‘cultural competence’ there is less
material on reporting and monitoring of cultural competence, and scant literature on
benchmarks and indicators.
Inclusion and Exclusion Criteria: Articles were included if they defined cultural
competence and cultural diversity in health settings, provided models of cultural
competence in health care and explored issues in implementation of cultural
competence in health settings such as planning, reporting, standards, indicators and
challenges/enabling factors. As there are a large number of articles on cultural
competence, those that did not relate to health settings were generally excluded.
Articles covered were in English only, excluding materials that were in other
languages.
Limitations: The searches were conducted for publications dating back to 1990. No
other limitations were set.
Information Sources: A wide range of information sources were searched
including:













Medline
Cumulative Index to Nursing and Allied Health Literature (CINAH)
The Agency for Healthcare Research and Quality website
Multicultural Australia and Immigration Studies (MAIS)
Cochrane Library
Proquest
Sage Journals on-line
Google Scholar
Georgetown University- National Centre for Cultural Competence website
European Commission Migrant Friendly Hospitals Project website
American Government Websites
Commonwealth Government Websites
State Government Websites (NSW, Victoria, Queensland, South Australia).
8
3. DEFINING CULTURE, CULTURAL COMPETENCE
AND CULTURAL DIVERSITY
Various definitions of culture, diversity, cultural diversity and cultural competence
were generated from relevant literature. However before defining cultural diversity
and cultural competence, it is vital to understand the concept of culture. Culture is a
much written about concept; as early 1871 Edward Tylor defined it as: ‘…that
complex whole which includes knowledge, belief, arts, morals, law, custom, and any
other capabilities and habits acquired by man as a member of society.’ In 1952,
Kroeber and Kluckhohn claimed to have identified 160 different definitions
representing different groups, for example, Topical, Behavioural, Normative,
Functional, Mental, Structural, and Symbolic. Given the scope and complexity of the
concept, culture, resists any exhaustive or conclusive definition (Effa-Ababio, 2005).
Diversity as a concept is broad and tends to refer to groups or individuals that are
perceived to be different from the general community (Centre for Culture Ethnicity
and Health, 2003). Cultural diversity is also another broad concept; however it tends
to focus on the rights of individuals and groups. UNESCO’s Universal Declaration on
Cultural Diversity, adopted unanimously in 2001, is the most articulated
understanding of cultural diversity. The declaration promotes cultural diversity to the
level of common heritage of humanity, implying it as ‘a source of exchange,
innovation and creativity…as necessary for mankind as biodiversity is for nature’
(UNESCO, 2002).
The term cultural and linguistic diversity refers to the range of different cultures and
language groups represented in the population. In popular usage, culturally and
linguistically diverse communities are those whose members identify as having nonmainstream cultural or linguistic affiliations by virtue of their place of birth, ancestry
or ethnic origin, religion, preferred language or language spoken at home. Aboriginal
organisations prefer that the needs of Australian Aborigines be considered
separately, rather than under the framework of cultural and linguistic diversity
(Department of Human Services, 2006 pp. 43).
Although the notion of cultural competence is not conclusive there is some
acceptance in the academic community about its definition as suggested by Cross et
al (1989). Accordingly, cultural competence is a set of congruent behaviours,
attitudes and policies that come together in a system, agency or among
professionals and enable that system, agency or those professionals to work
effectively in cross-cultural situations (Cross et al, 1989). Cultural competence can
be viewed at an individual level whereby it is the ability to identify and challenge
one’s cultural assumptions, values and beliefs (Fitzgerald, 2000). As well, it can be
more than an awareness of cultural differences, as it can be used to improve health
and well being by integrating culture into the delivery of health services (National
Health and Medical Research Council, 2005).
Efforts to define cultural competence and its application within the health care
context are continuing. The National Quality Forum notes (2002) that there is an
absence of standardised frameworks, logic and definition of cultural competence.
While the case for the benefits of cultural competence from a clinical and business
standpoint is accepted, the major challenge is how to define, assess and measure
9
cultural competence (Betancourt et al 2002, Brach and Fraser 2000). Definitions
have focused on the individual or clinician level, and the organisational level. Some
definitions recognise both the individual, organisational or structural aspects of
cultural competence.
The definition of cultural competency ‘culture’ is often reified and not treated as a
dynamic and changing factor increasing the risk of perpetuating cultural stereotypes
(Greg and Saha, 2006). Various definitions of cultural competence exist however, the
definition by Cross et al (as noted above) seems to be most widely quoted. Although
there is no consensus on a single defining there is some agreement that building
cultural competence capacity will improve health care delivery to diverse populations.
10
4. RELEVANCE OF CULTURAL COMPETENCE TO
HEALTH AND WELLBEING
Australia is a multicultural country with approximately one in four people being born
overseas. Victoria is among the fastest-growing states in Australia and according to
the 2006 ABS Census, had a resident population of almost five million people. Net
overseas migration has consistently accounted for more than half of Victoria’s
population increase. In Victoria 23.8 per cent of the population were born overseas
and an additional 19.7 per cent of Victorians, born in Australia, had either one or
both parents born overseas. This diversity is growing faster than at any other time in
Victoria’s history and the trend is expected to continue.
The National Health and Medical Research Council (NHMRC) points out that:
All Australians have the right to access health care that meets their needs. In our
culturally and linguistically diverse society, this right can only be upheld if cultural
issues are core business at every level of the health system-systemic, organisational,
professional and individual (NHMRC 2006, pp.1).
For many migrants and refugees the impact of settlement and acculturation varies
widely depending on their experience and circumstances. Health and wellbeing are
governed by many factors, some outside the health system, such as housing,
employment, education, community networks and supports and access to essential
services. In reality the health and wellbeing of culturally and linguistically diverse
communities depends on a complex balance of social, economic, and environmental
factors.
The promotion of healthier living for culturally diverse communities is linked to both
‘risk’ and ‘protective’ behaviours that are related to immigration, ethnicity, ‘race’ and
culture. Risk factors are characteristics, variables, or hazards that, if present for a
given individual, make it more likely that this individual, rather than someone
selected at random from the general population, will develop a disorder (Multicultural
Mental Health Australia, 2005). Protective factors reduce the likelihood of a person
suffering a disease, or enhance their response to the disease should it occur (AIHW,
2002).
The health status of migrants can vary according to a range of factors, which include
not only country of birth and levels of English but also the process of migration,
stage in the life course, community capital and support and each individual’s balance
of protective and risk factors.
While immigrants and refugees often enter Australia with better physical health due
to screening processes (NSW Health, 2004) they may have worse levels of mental
health that are associated with the stressors of migration (Reid and Tromph, 1990)
and any health advantage shown by immigrants usually disappears over time. This
effect has been documented for physical health outcomes such as cardiovascular
disease, cancer, and mental health (AIHW, 2004).
The Institute of Medicine (2008) concludes that one major contributor to health
inequalities is a lack of culturally competent care and that by providing culturally
11
appropriate services there is potential to reduce disparities and improve outcomes,
increase efficiency of clinical and support staff and improve satisfaction among
patients. ‘Culture’ is central in the delivery of health care services, since it can
influence patients’ health beliefs, medical practices, attitudes towards medical care,
and levels of trust. Cultural differences can impact on how health information is
provided, understood, and acted upon. Clinical barriers in health care delivery could
be overcome by addressing cultural differences, and result in improved access and
quality of care for culturally diverse populations.
Cultural competence in healthcare has emerged partially as a strategy to address
racial and ethnic disparities that may lead to health inequalities. Betancourt, Green
and Carrillo (2002) conclude cultural competence in healthcare systems shows the
ability of systems to provide care to patients with diverse values, beliefs, and
behaviours, including meeting patients’ social, cultural and linguistic needs. They
state that the goal of cultural competence is to create a health care system and
workforce that are capable of delivering the highest-quality care to every patient
regardless of race, ethnicity, cultural background and English proficiency.
Cultural competence has been promoted as a way for health services and
organisations to respond effectively to the cultural and linguistic needs that patients
bring to the health care encounter (US Department of Health and Human Services,
2001). It focuses on the capacity of the health system to improve health and
wellbeing by integrating culture into the delivery of health services (NHMRC, 2005).
Cultural competence then requires organisations to have a clearly defined and
matching set of values and principles, as well as policies and structures that enable
them to work effectively in cross-cultural situations. Brach and Fraser (2000) are
able to demonstrate that health systems and clinicians’ ability to deliver appropriate
services to diverse populations can be improved; they conclude that cultural
competence should work, and found health systems have limited evidence to suggest
otherwise.
Anderson, Scrimshaw, Fullilove, Fielding, and Normand (2003) reviewed five
interventions to improve cultural competence in health care systems, but they could
not determine the effectiveness of any of these interventions because there were
either too few comparative studies, or the studies did not examine the outcome
measures their review was evaluating.
In the Australian context, NHRMC (2006:4) notes that a health system that is
culturally competent:




acknowledges the benefits that diversity brings to Australian society;
helps health Services and consumers to achieve the best, most appropriate care
and services;
enables self-determination and ensures a commitment to reciprocity for culturally
and linguistically diverse consumers and their communities; and
holds governments, health organisations and managers accountable for meeting
the needs of all members of the communities they serve.
12
5. MODELS OF CULTURAL COMPETENCE
In the closing plenary of a convention on ‘Building Culturally Competent Health
Systems in California’ Joseph Betancourt, Director of the Disparities Solutions
Centre, Massachusetts, General Hospital stated, ‘…ultimately what we want is a
health care system that can respond to the need of any patient’. This statement begs
the question, ‘what needs to be done to create a health care system that has the
ability to respond to any patient’s need?’ This section will explore potential answers
to that question through key models of cultural competence and their outcomes in
the context of both Australian and overseas health care systems.
A number of models of cultural competence have been developed, which encompass
the different dimensions that cultural competence should address.
In an influential model, developed by Cross et al (1989) cultural competence is
envisaged as a continuum through:


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


Cultural
Cultural
Cultural
Cultural
Cultural
Cultural
destructiveness
incapacity
blindness
pre-competence
competence
proficiency.
A key model is that developed by Campinha-Bacote (1999, 2002) who argues that
cultural competence has five interdependent elements:





Cultural
Cultural
Cultural
Cultural
Cultural
Awareness
Knowledge
Skills
Encounters
Desire.
Cultural awareness involves a process of self-examination of one’s own cultural and
professional background and biases towards others and being aware of one’s own
prejudices that may affect health care delivery. Cultural knowledge is gaining an
understanding of the world-views of different cultural and ethnic groups, and seeking
information on how diseases and health conditions affect particular groups.
Cultural skill is the ability to collect relevant data on the client’s presenting problem
and to know their overall health status. Cultural encounters are the process of
engaging with individuals from other cultures with the view to modifying existing
assumptions about a cultural group and prevent stereotyping. Finally, cultural desire
is the motivation of an individual to engage in each of the stages of being coming
culturally competent as described above.
The progression from cultural destructiveness whereby the attitudes, policies and
practices are destructive, systems not being intentionally destructive, systems being
perceived as fair for all to the knowledge that systems have flaws in dealing with
minority issues, respect for differences, and finally to cultural proficiency holding
cultural differences and diversity in high esteem. This model represents an
13
interesting view that perceives organisations moving through two extremes on the
continuum through time. Muriel Bamlett (2007) has applied this as a useful concept
to understanding cultural competence in Aboriginal Children’s Services and has
illustrated how this model can be used to analyse approaches by mainstream
agencies to Aboriginal culture and history such as the Stolen Generations.
The National Health and Medical Research Council (2006:29) model acknowledges
four dimensions of cultural competence:
Systemic — effective policies and procedures, mechanisms for monitoring and
sufficient resources are fundamental to fostering culturally competent behaviour and
practice at other levels. Policies support the active involvement of culturally diverse
communities in matters concerning their health and environment.
Organisational — the skills and resources required by client diversity are in place. A
culture is created where cultural competence is valued as integral to core business
and consequently supported and evaluated. Management is committed to a process
of diversity management including cultural and linguistic diversity at all staffing
levels.
Professional — over-arching the other dimensions, at this level cultural competence
is identified as an important component in education and professional development.
It also results in specific professions developing cultural competence standards to
guide the working lives of individuals.
Individual — knowledge, attitudes and behaviours defining culturally competent
behaviour are maximised and made more effective by existing within a supportive
health organisation and wider health system. Individual health professionals feel
supported to work with diverse communities to develop relevant, appropriate and
sustainable health promotion programs.
Health care systems, embracing this model, need to allocate appropriate resources
to ensure cultural competence is embedded into organisations, for example to
conduct policy, organisational and professional training and assessment procedures.
Andrulis (2003) identified five dimensions that address the major causes of
disparities that can exert significant influence over the success and quality of the
patient-physician relationship, treatment plans, and health outcomes. These are:





biological and genetic influences;
differential access to care;
quality of care disparities;
clinical-patient perceptions and realities;
language and communication barriers.
In another study that focussed on reducing ethnic children’s health disparities,
Andrulis (2005) suggests the need to:


collect and use race/ethnicity data for the review of program, service, and Health
Service effectiveness;
bridge the communication divide to reduce language and communication
barriers; and
14

develop knowledge and skills that integrate factors affecting children from diverse
backgrounds.
In doing so, oral and written materials must accommodate a diverse range of health
literacy needs and reflect an understanding of life course experience. For example,
understanding the role and legacy of racism and discrimination on health and familial
relationships, recognising the significant influence of culture on health, and
understanding the cultural context for health care decision-making is critical for
effective clinical encounters. Understanding the role, norms, or customs of the family
in medical decisions, healing practices, rituals, and other culturally influenced
priorities must be integrated into health care interactions, as well as integrating
cultural competence into quality of care. Andrulis talks of the need ‘for research to
extend through and beyond the clinical encounter to address the role of the health
care setting and system’ (Andrulis 2005, pp. 377), with each health care setting
recognising its importance to the process.
The framework proposed by Brach and Fraser (2000) is developed based on
knowledge gained from fieldwork undertaken across sectors and so captures realistic
issues and offers practical suggestions. It is a holistic framework that incorporates
nine categories of cultural competence in health settings:

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



Interpreter services, as the most common way to improve communication among
persons who speak different languages.
Recruitment and retention of minority staff or, more generally speaking, staff
who reflect the demographics of the patient population.
Training in cultural competence, aimed at increasing cultural awareness,
knowledge and skills, leading to changes in staff (both clinical and administrative)
behaviour and patient-staff interactions.
Coordinating with traditional healers, health professionals needing to coordinate
with these healers, as they would with any other care provider. In addition,
presenting patient education in a conceptual framework that harmonises with
traditional healing practices may increase the chances that patients will concur
with treatment recommendations.
Use of community health workers as they are known and respected by the
community, and can serve as guides to the health system, (their advocacy and
empowerment function is important).
Culturally competent health promotion. This can take several forms: health
professionals’ screening tools, brief interventions, public information campaigns.
The health promotion messages can be made more culturally competent and
specific.
Including family and/or community members. While patient autonomy has
become a core principle of Western health care, some minority groups involve
family members in health care decision-making.
Immersion into another culture. Immersion enables participants (health
professionals) to overcome their ethnocentrism.
Administrative and organisational accommodations. A variety of administrative
and organisational decisions related to clinic locations, hours of operation,
network membership, physical environments and written materials can also affect
access to and use of health care
These categories attempt to provide rigor from various points of health provision that
can work at multiple levels such as organisational, community, and in education and
training, recruitment, and interface between traditional healers and health
15
professionals. The conceptual framework does not address the need for additional
resources to make many of these activities possible. The authors also note that there
is insufficient research evidence to suggest the effect of particular cultural
competence techniques on any outcomes, including racial and ethnic disparities
(Brach and Fraser, 2000).
Betancourt et al (2002) identified benefits of cultural competence to the health care
systems by interviewing health care experts in government, managed care,
academia, and community health care delivery. Based on their exploratory exercise
they came up with some key suggestions for developing the cultural competence
framework. Accordingly, health care requires an understanding of the communities
being served including the impact of socioeconomic influences on individual patients’
health beliefs and behaviors, and how these factors interact with the health care
system in ways that may prevent diverse populations from obtaining health care.
Then, there is a need to devise strategies to reduce and monitor potential barriers
through interventions.
The authors provide a framework for the implementation of culturally competent
practices based on these suggestions. The framework includes the following
components:



Organisational cultural competence: This involves reflection of racial and ethnic
diversity in health care leadership and work force. Inclusion of community
members in health care process and formally including community health
advocates and recruiting staff from diverse communities would enhance cultural
competence in the organisation.
Systemic cultural competence: Systemic barriers such as a lack of interpreter
services, culturally and linguistically appropriate health education materials can
lead to patient dissatisfaction, poor comprehensive and compliance, and lower
quality care.
Clinical cultural competence: The role of cross-cultural education and training
including education in cultural competence for senior management, health
services, and staff is vital in the provision of quality care. The focus of training
should be on socioeconomic factors, communication skills, and mechanisms for
addressing racism and bias. Patient empowerment is also a source of cultural
competence.
Strategies for attaining cultural competence included:



using health care purchasers (government and private),
developing contractual requirements (federal and state), and
formulating accreditation standards (for example, for hospitals and medical
schools).
Jirwe, Gerrish and Emami (2006) identified nine most frequently cited models of
cultural competence and undertook a content analysis that revealed four themes:
1. An awareness of diversity among human beings to provide a culturally competent
care; this is based on the premise that to know the other culture one needs to
know one’s own.
2. An ability to care for individuals requires the need to communicate effectively
with the clients to know the client needs and their belief systems and to develop
a mutually acceptable health management plan;
16
3. A non-judgemental openness—an aspiration on the part of the health service to
overcome their own prejudices, in order to provide culturally sensitive care; and
4. Enhancing cultural competence as a long-term continuous process that requires
learning, reflection and improvement on the part of Health Services.
Romeo (2007, pp. 206) states that cultural competence is a ‘learning process that
enables individuals and organisations to function effectively in the midst of cultural
difference’. He points to the need to view cultural competence as an ongoing process
of organisational transformation in a continuum from early to later stages of
development. This means, that for health care organisations to become more
culturally competent they will need to engage in a change process of organisational
transformation. This entails engaging in a change process from a monoculture to a
pluralistic environment, or an environment that accepts and integrates people from
diverse cultural backgrounds. A number of models of organisational change for
cultural competence have been put forward which develops cultural competence in
agencies.
Tirado (1998) proposes a five-stage model of organisational change:
1.
2.
3.
4.
5.
Culturally
Culturally
Culturally
Culturally
Culturally
resistant
unaware
conscious
insightful
versatile.
Similarly, Dreachslin (1996) proposes a five-stage change model from affirmative
action to valuing diversity encompassing a number of dimensions:
1.
2.
3.
4.
5.
Discovery
Assessment
Exploration
Transformation
Revitalisation.
5.1 Discussion and Analysis: How do the models guide
intervention?
All these models have both strengths and weaknesses. The models point to elements
of change:


Identifying where and how change can occur along a continuum; and
Suggesting that the cultural continuum is not an end point but an ongoing
process.
The usefulness of the models lies in unpacking the different dimensions of what they
suggest might constitute cultural competence and in determining strategies for
action. As noted earlier in the paper there is no conclusive definition of cultural
competence, and that the notion of culture tends to be oversimplified in the notion of
cultural competence (Gregg and Saha, 2006). Cultural competence models tend not
to consider the structural causes of health care inequalities (Gregg, Bussey-Jones,
Fernandez and Lemon, 2005). However as cultural competence is gaining popularity
17
in health care and social policy there is a need for a clearly defined and agreed upon
definition, framework, and criteria to implement and assess its efficacy.
There are a number of assessment tools that have been developed (see below) as
instruments to measure change. Berson and Iscel (2006) advocate a case for a
culturally inclusive holistic approach to implementing cultural competence through
various initiatives, projects and strategies in order to reach different target groups in
the community. This approach has been used at the Ethnic Disability Advocacy
Centre, in Western Australia, and has resulted in many positive outcomes for
individuals, industry and the community.
The approach includes provision of services such as: employment, independent
living, education, home care, health, recreation, transport, and advocacy taking into
consideration cultural care, cultural values, cultural responsibilities and cultural
practices. At the same time vital feedback from the consumers and carers is received
and utilised to further improve services.
This inclusive system of service delivery strives for substantive equality with both
health service and the consumers. It illustrates provision of services in a culturally
competent manner, as consideration is given to cultural care, values, responsibilities
and practices. In some ways this approach is similar to a quality assurance system
whereby quality of a system is improved through monitoring and feedback.
The Centre for Cultural Ethnicity and Health (2003) conclude that quality
improvement can provide a broad framework for responding to the needs of
individuals and groups from non-English speaking backgrounds. They suggest the
following characteristics to be associated with organisations that continually improve
their performance: a patient/client group focus; strong leadership; a culture of
improving; evidence of improved outcomes and a commitment to striving for best
practice. From the above example, it can be assumed that in order to ensure that the
needs of individuals and groups from Non-English speaking and CALD backgrounds
are met the issue of equity needs to be treated in the same manner as the issue of
quality.
In an effort to address cultural diversity in Australian health services, a study was
undertaken by Allotey, Manderson and Reidpath (2002) that used applied
anthropological approaches to negotiate style and content for a set of resource
materials designed to be used by health Services in community health and hospital
settings. The resulting guide shows best practice for clinical care regardless of
cultural or linguistic diversity, and would assist health services to avoid stereotyping
by encouraging staff to ask their patients questions. This approach is based on the
philosophy that rather than using a pre-existing checklist on cultural imperatives to
obtain cultural knowledge a health care professional would ask their patient ‘who is
the cultural expert’ not them. It requires a respect for the ‘expertise’ of the patient
and incorporates the active involvement of each patient and their family/carers.
Australian Health Minister’s Advisory Council (2004) advocated an Indigenous
framework that included knowledge and awareness, skilled practice and behaviour,
strong relationships and equity of outcomes. This model was grounded on the
premise that an understanding of cultural heritage coupled with formal education and
training would instigate a change in attitudes and behaviour that then needs to be
endorsed through a strong management process. The model requires a balanced
workforce inclusive of Aboriginals and Torres Strait Islander people; management
18
being sensitive to cultural needs and risk management that reflects cultural
differences. It proposed the need for equity of outcomes for both individuals and
communities achieved through quality assurance mechanisms.
Anderson et al (2003) reviewed five interventions to improve the cultural
competence of health care systems. The interventions included:
1. programs to recruit and retain staff reflecting cultural diversity of the community
served
2. use of interpreter services for clients with limited English proficiency
3. cultural competence training for healthcare worker
4. use of linguistically and culturally appropriate health education material
5. culturally specific health care settings.
The authors state they could not determine the effectiveness of these interventions
because there were either too few comparative studies, or the studies did not
examine the outcome measures evaluated in the review. These outcomes were:
client satisfaction with care, improvement in health status, and inappropriate racial
or ethnic differences in use of health services or in received and recommended
treatment. The major drawback of this review is that the interventions were carried
out over time and in different settings. Perhaps the results would have been different
if the interventions were undertaken in conjunction with other changes at
organisational level such as commitment at senior management level with a defined
plan and allocation of resources.
The models described in this section provide some guidance for interventions, and
specific examples have been provided. While we are aware that there is good
practice, the literature on this field is scant. We were unable to find any further
studies evaluating the success or impact of these interventions.
19
6. CULTURE AS A FACTOR IN SAFETY AND RISK
MANAGEMENT IN HEALTH SYSTEMS
The benefits of integrating cultural competence into health care have been well
established. According to Stewart (2006) culturally competent health care is a good
business practice, a better use of resources, and helps to:





improve access and equity for all groups of population;
improve consumer health literacy and reduced delays in seeking health care and
treatment;
improve communication and understanding of meanings between health
consumers and Health Services;
improve patient safety and quality assurance, and
improve public image of a health service.
Most of the practice frameworks in Australia have engaged with cultural diversity in
heath care from an inclusion and multiculturalism perspective. There are other
related ways to consider ‘culture’ in health systems. The following section will discuss
key issues and challenges of integrating cultural competence into health care.
Safety and Managing Risk
Several studies show that minority and migrant patients are not receiving the same
level of health care in terms of diagnosis, treatment and preventative services that
the average population receive (Johnstone and Kanitsaki, 2006; 2007) and are less
likely to receive the same level of care for numerous health issues including: less
aggressive treatment of colorectal cancer; they receive fewer orthopaedic procedures
(Ronsaville and Hakim, 2000) more misdiagnosis of mental illness with less adequate
treatment (Fiscella, 2002). More recently, Paradies (2006) found that the
relationship between discrimination and poor mental health is well established.
Overall, this literature suggests that that in Australia and internationally the health
status of racial and ethnic minority groups tends to be poorer than that of the
average population of the countries in which they reside (Anderson et al 2003;
Johnstone and Kanitsaki, 2007; Kelly and Bancroft, 2007; Kreps, 2007; King et al,
2008; Like, 2007; Serizawa, 2007; Smith and Betancourt et al, 2007). From these
studies, we can conclude that the health disparities may be a result of inadequate
interaction between health and culture and/or due to the inability of healthcare
systems to address the health care needs of individuals from CALD background.
With regard to the Australian context, Johnstone and Kanitsaki (2006) contend that
those responsible for the design and delivery of health care can do more to improve
the status quo in regard to ensuring the responsiveness of the Australian health care
system to the health and care needs of resident minority racial and ethnic groups,
and that much more needs to be done.
20
These issues offer insights into what health services in Australia should be doing.
NHMRC (2005:16) point out that for the health sector in Australia will need to:






Address similarities and differences within communities based on gender, age,
length of stay, literacy and beliefs;
Implementing policies to ensure equity and access to health services and
promotion for a diverse population;
Plan and delivering culturally competent and appropriate health promotion and
health services;
Address systemic attitudes to cultural diversity that can influence how
communities survive and succeed;
Address research gaps about the contribution of systemic risk factors (such as
access to health services) to inequalities in health for CALD background
communities; and
Develop and maintain a culturally competent health workforce.
According to Bischoff (2003) a number of factors are likely to be relevant in culture
as a factor in safety and risk management. These can include a trajectory of errors
and risks in health systems relating to:











Diagnostic testing
Medication
Pain management
Medical follow-up
Admission
Referral
Food and diets
Patient adherence
Patient information/understanding
Patient reporting/complaints
Patient participation.
The Institute of Medicine (2002) in USA argues that patient safety is not solely about
addressing general systems issues to prevent the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim (such as
administering the wrong medication or dosage). It also entails: avoiding
misdiagnosis; preventing patients from exposure to unnecessary risks; and ensuring
informed consent. Similar issues are confirmed by Flores (2000) in that failure to
consider a patient’s cultural and linguistic issues can result in:












Inaccurate histories
Decreased satisfaction with care
Non-adherence
Poor continuity of care
Less preventive screening
Miscommunication
Difficulties with informed consent
Inadequate analgesia
A lower likelihood of having a primary care provider
Decreased access to care
Use of harmful remedies; delayed immunisations
Fewer prescriptions.
21
These issues clearly suggest risk to both health services and their clients.
The stated mission of the Australian Council on Healthcare Standards (ACHS), the
national independent bodies which determines accreditation standards for health
services, is to ‘improve the quality and safety of health care’ this includes cultural
safety (http://www.achs.org.au). However, there is no doubt that every aspect of
care delivered to culturally and linguistically diverse clients has the potential to be
less than optimal if language and cultural barriers are not addressed as a matter of
priority.
A recent study conducted by Johnstone and Kanitsaki (2007) found that most
participants interviewed had not previously heard of the term ‘cultural safety’ before
receiving information from the researchers. On a more positive note however, it was
also noted that participants had a sense that cultural safety was a complex process
primarily concerned with health services ‘doing things safely’. This they believed
could be achieved by ensuring that patients from minority racial and ethnic
backgrounds got safe care and did not suffer mishaps and harm because of
ineffective communication or because of lack of cultural awareness on the part of
staff.
A lack of risk management of cultural differences can lead to major issues for both
health services and recipients. According to Johnstone and Kanitsaki (2006) issues of
culture and language and the risks associated with cultural misunderstandings and
failure to use professional health interpreters have long had legal implications in
terms of preventable adverse events in patients of minority backgrounds. These
authors cite many examples of litigation.
They highlight the need for a more strategic and systematic approach to health
service delivery to culturally and linguistically diverse groups and the need to set as
a national priority the ‘alignment of cultural safety and cultural competence
initiatives with national and local organisational clinical risk management programs
and related patient safety and quality care initiatives.’
Proposed Strategic Framework and Standards
 Developing and implementing a national strategic framework for improving
culturally and linguistically appropriate services in healthcare in Australian states
and territories.
 Developing and operationalising national standards for culturally and linguistically
appropriate services in healthcare in Australian states and territories. The
standards developed should have their focus mandates, guidelines, and
recommendations pertaining to:
o Culturally safe and culturally competent care (including culturally competent
and safe organisations)
o Language access services
o Organisational supports for cultural safety and cultural competence (including
mandates for funding bodies to ensure the provision of appropriate human
resources and funding).
Central to this, Johnstone and Kanitsaki (2007 pp.181) highlight the need to develop
and implement a national agenda for research on cultural safety and cultural
competence in healthcare under the auspices of NHMRC/ARC.
22
Quality of Care and Culture
It is noted by Omeri (2004:26) that governments hold health services accountable
for delivering services that are appropriate for consumers from culturally and
linguistically diverse backgrounds, with the aim to reduce racial, ethnic and social
disparities in health care and health outcomes. This raises the question of cultural
competence as an issue of quality and quality assurance. Organisations need to
integrate cultural competence into their internal quality improvement activities; this
can be fundamental to an organisation-wide approach to planning and
implementation of continuous improvement in performance. Performance measures
that relate cultural competence as part of overall performance management will
assist in ‘culture’ being included in quality assessments. Including these measures in
performance management systems elevates their importance for the institution.
There is substantial evidence that language barriers and miscommunication have
adverse affects on the quality of care received, patient satisfaction and patient health
outcomes (Bischoff, 2003; Johnstone and Kanitsaki, 2007; Kelly and Bancroft, 2007;
Markove and Broom, 2007). The quality of physician/patient communication affects
outcomes, with many at double risk: at risk of receiving less optimal care because
they are part of a minority community and the additional risk posed by language
barriers (Stewart et al, 2000; Bischoff, 2003).
The standard of patient-provider communication is a strong indicator of the quality of
health care provided. According to Bischoff (2003) less satisfactory aspects of care in
language discordant consultations lead to issues with quality such as:




meeting patients’ needs
giving explanations
showing respect during the consultation process
giving follow-up information.
Lack of explanation about medication correlated with later non-adherence and
patient dissatisfaction (Manderson and Allotey, 2002); poor compliance to
medications and health promotion strategies, poorer health outcomes (Brach and
Fraserirector, 2000; Flores, 2000) was also noted. In addition, it was found that
patients were more likely to miss follow-up appointments and skip medication and
more likely to use hospital emergency rooms and have longer median in-patient days
in hospital (Levin-Zamir, 2007).
Research tells us that there is a conclusive link between cultural and language
considerations in clinical contexts. However, Johnstone and Kanitsaki, (2006:383)
point out that, researchers are slow to demonstrate that link. These authors argue
that patient safety programs tend to underestimate or understate the critical
relationship that exists between culture, language and safety and quality of care and
that if this issue is not addressed patients from culturally and linguistically diverse
backgrounds are exposed to preventable risks.
Betancourt (2006a) reviews specific quality improvement approaches, such as
disease management (DM) and the chronic care model (CCM), and identifies areas
where cultural competence could be embedded:

Identify patients who need care: Since both the CCM and DM create registries of
patients with specific chronic conditions (for example, diabetes), a culturally
competent approach would ensure that these registries are stratified by race,
23




ethnicity, and language proficiency and thus geared to identify racial/ethnic
disparities in health care.
Provide care by tailoring the methods used to the patient's needs: In CCM and
DM programs, physicians, case management nurses, and other members of
multidisciplinary care teams seek to communicate with patients outside of the
traditional office visit, for example, through telephone contact, e-mail, and group
visits. A culturally competent approach would establish ways to communicate
with patients with limited English proficiency, limited health literacy, alternative
health beliefs, and other needs.
Support physicians and multidisciplinary teams in their clinical decision-making:
Once sociocultural barriers to care are identified and interventions to address
them are put in place, physicians could be enlisted to help. For example,
physicians could be provided with information solicited by other health care team
members regarding patients' understanding of their conditions or their fears and
concerns about a medication. Thus, physicians' clinical decision-making and care
management strategies could be informed by information about patients'
sociocultural barriers to care and can engage in culturally competent approaches
to address them.
Support patients in their ability to help manage their own illnesses: To make this
process culturally competent, educational information could be provided to
patients in the appropriate languages and reading levels. In addition, selfmanagement advice and strategies should take into account key issues related to
patients' social context, such as their physical environment and ability to
exercise.
Provide physicians, teams, and physician organisations with feedback on their
performance: Stratifying performance feedback by race, ethnicity, culture, and
language proficiency would enable health teams to identify issues as they arise,
and address them as they emerge in distinct populations.
Patient Centred Care and Culture
Patient centred care is defined as care that is respectful and responsive to individual
patient preferences, needs and values and that these values guide all clinical
decisions (Beach and Saha et al, 2006). Evidence exists that health services who are
at the forefront of caring for people from CALD backgrounds do not have an
acceptable level of knowledge and understanding of the nature and implications of
cultural competence in health care (Chenoweth, Jeon and Burke, 2006; Campesino,
2006: 298; Cioffi, 2005; Johnstone and Kanitsaki, 2007; Smith and Betancourt,
2007; Westwood, 2008). When health services fail to understand socio-cultural
differences between themselves and their patients, communication and trust
between them may suffer leading to a perceived or actual diminishment in the
quality of care expressed by patients (Johnstone and Kanitsaki, 2006).
Both patient-centeredness and cultural competence aim to improve health care
quality, but each emphasizes different aspects of quality. The primary goal of the
patient-centeredness movement has been to provide individualised care and restore
an emphasis on personal relationships. It aims to elevate quality for all patients.
Beach et al (2006) point out that there is congruence between cultural competence
and patient-centred care. They state:
‘…to deliver individualised care, a provider must take into account the diversity of
patients' perspectives, and so—to the extent that patient-centred care is delivered
universally—care should become more equitable. Likewise, to the extent cultural
24
competence enhances the ability of health care systems and providers to address
individual patients' preferences and goals, care should also become more patientcentred’ (2006).
Smith (2002) and the Department of Human Services (2008) suggest that migrant
and minority health care issues need to be framed as quality issues; and that
interventions need to focus on the quality of overall care at both individual and
organisational levels. Congruent with this view Johnstone and Kanitsaki (2007) note,
that cultural safety should be viewed both from the perspective of the consumer and
the Health Service. Therefore changing the attitudes and behaviour is necessary in
order to achieve results in the medium and long term, as there is evidence that
institutional discrimination has an influence both on health outcomes and on
community attitudes (VicHealth, 2007). It is noted in the Lewin Report (2002) that
the multifaceted and interconnected nature of cultural competence domains tend to
overlap and do not occur in mutually exclusive categories. Congruent with this view
the Australian Resource Centre for Healthcare Innovations (ARCHI: 1) provide this
definition of a culturally competent health care system:
‘…staff within a culturally competent health care system honour and respect beliefs,
interpersonal styles, attitudes, and behaviours of individuals, families and
communities they serve. Cultural competence is a life-long process which includes
the examination of one’s own attitudes and values, and the acquisition of knowledge
and appreciation of cultural differences and similarities within, among, and between
groups. A culturally competent system of care reflects and responds to the
communities it serves through its administrative policies and procedures, hiring
practices, training and professional development, and the active participation of
community members and consumers. Self-assessment, culturally based needs
assessments, and the active incorporation of findings from these assessments into
practice are essential elements of culturally competent systems.’
Patient-centred care can be described generally as an approach that emphasises
attention to patients’ psychosocial as well as physical needs. The implication for
CALD clients is that their cultural needs, histories and social contexts that impact on
health will be taken into account. This approach also emphasises that treatment
choice takes patient preferences into account, and that self-care is supported as well
as treatment. Central to this is the development of a sense of partnership in care,
and facilitation of patient involvement in decision making about treatment decisions;
if a service is not culturally sensitive, then partnership with patients in care will be
ignored. This will impact negatively on communication about diagnosis and
treatment. Patients have been found to prefer patient-centred care, and those who
receive it, also report better health outcomes (Little et al, 2001).
According to Smith and Betancourt et al (2007) in order to address racial and ethnic
health disparities from the consumer provider perspective it is necessary to examine
and understand attitudes, such as mistrust, subconscious bias, and stereotyping,
that health service staff and patients may bring to the clinical encounter. In order to
attain higher levels of quality of care for CALD clients within hospital systems, health
services must firstly be made aware of the impact of social and cultural factors on
health beliefs and behaviours; understand the impact of stereotyping (Taylor and
Lurie, 2004); be equipped with the tools and skills to manage these factors
appropriately through training and education and they should empower patients to
be active partners (Betancourt and Carrillo, 2002; Johnstone and Kanitsaki, 2007).
25
Lewin, Skea, Entwistle, and Zwarenstein (2001) undertook a study on patientcentred approach in clinical consultations and concluded that interventions to
promote patient-centred care within clinical consultations may significantly increase
the patient centredness of care. However, there is limited and mixed evidence on the
effects of such interventions on patient health care behaviours or health status; or
on whether these interventions might be applicable to Health Services other than
physicians.
The Victorian Government Department of Human Services has commissioned the
National Ageing Research Institute to support and evaluate best practice in personcentred health care in Victorian Health Services (Dow, Haralambous, Bremner, and
Fearn, 2006). The aim of this initiative is to make sure that older people are being
cared for in the context for their individual situation, and to empower them and the
people who care for them to be involved in decision-making. The Program delivers a
strategic and comprehensive response to assist staff in providing quality care to
patients from CALD backgrounds. It includes co-ordination of language services,
including interpreting and translating, staff development, and policy and procedure
development and implementation. Key issues in person-centered care involve
effective participatory approaches. The Department has identified the following key
priority actions:










Promote the rights and responsibilities of patients to the community, consumers
and carers;
Communicate clearly and respectfully with consumers and carers;
Provide accessible information to consumers, carers and community members
about health care and treatment;
Communicate and provide information about treatments and care to consumers
and carers that is developed with consumers and, where appropriate, carers
listen and act on the decisions their consumers make about their care and
treatment;
Integrate participation of consumers, carers and community members,
representatives or nominees into the quality and safety program;
Community representatives or nominees to be involved in the review of system
level issues regarding consumer and carer feedback and complaints;
Include the involvement of consumers, carers, community members,
representatives or nominees in all aspects of the organisation’s planning and
development;
Provide staff training and education on how to use the different types of
participation;
Ensure position descriptions include participation component ; and
Evaluate, monitor and report on participation to the community and the
Department of Human Services.
The survey found the Health Services lacked the service capacity to providing the
person centred care. The issue of capacity was even more pronounced for acute
services than sub-acute; the inability to provide care in an environment considered
most ideal for that person – that is, in the person’s home was also pronounced.
Various organisational support issues were also identified that require attention to
achieve both positive culture and practice change. For example, having good
management support and working within an organisation that values its staff was
identified as important. Barriers included high staff turnover, problems with staff
recruitment, staff feeling ‘pressured to discharge’ patients before they are ready and
lack of good mentoring. Working within an organisation that values and prioritises
26
the care of the older person, supports ‘top down’ the provision of person-centred
care and seeks to both receive and act on consumer feedback was also considered
necessary (Dow, Haralambous, Bremner, and Fearn, 2006: 70).
Brach and Fraser (2000) have also offered the notion of ‘family centeredness;
respecting the potential wish of culturally diverse groups to include their family
members in healthcare decision-making. While recognizing that certain privacy
regulations and laws exist, person centered approaches can accommodate familycentered care, as determined by the patient. Knowledge and understanding the role
that family play in healthcare decisions become important considerations. This
includes knowledge of culturally defined composition and roles within families; skills
necessary to communicate with family members with attention to age, gender;
include family members in decision making when requested; honor patient and
family perspectives and choices; and patient and family knowledge, values, beliefs
and cultural backgrounds are incorporated into the planning and delivery of care.
At the core of both patient centeredness and cultural competence is the emphasis on
seeing the patient as a unique person. The general characteristics of patientcentered care (for example, building rapport; exploring patient beliefs, values, and
the meaning of illness; finding common ground) may be endorsed as aspects of
cultural competence. Beach et al (2006) argue that because cultural context is
relevant to the needs of all patients, not only to those of culturally diverse
backgrounds, cultural competence has the capacity to enhance patient-centeredness
and improve quality for all patients.
From the above, it is evident that patient- centered care can provide a mechanism to
be inclusive of CALD patients in care delivery. There is a need to develop particular
kinds of policies and procedures in hospitals that support cultural competence. In
addition, there is a need for organisational commitment to cultural competence and
subsequent action at the policy and procedures level, as these initiatives can often
be overshadowed by other organisational priorities (Wilson-Stronks, Lee, Cordero,
Kopp, and Galvez, 2008).
Consumer Knowledge and Empowerment
Health literacy is a new concept that focuses on the ability to use the health care
system appropriately and to live a healthy lifestyle (Davis et al, 1998). Health
literacy is dependent upon education, past experience with the health system, age,
gender and culture. It is suggested by Levin-Zamir (2007) that it is important to
understand the association between cultural competence, empowerment and health
literacy for three specific reasons. First, she argues that the concepts form the basis
for improving health indicators. The next argument made is that, the empowerment,
cultural competence and health literacy connection has significance regarding the use
of public resources for health care and that health costs increase due to costs that
stem from the increased need for repeated examinations, treatment, hospitalizations
due to mistakes and misunderstandings. Finally, it is noted that the personal cost
can be of personal shame and harm that is caused to self-esteem by an unpleasant
encounter with a health service. In a study conducted by VicHealth (2007) it was
found that the health consequences of discrimination can be moderated if people
have a positive ethnic identity and a realistic appraisal of the existence and extent of
discrimination affecting their group. It is also important that patients should be
aware of their own attitudes, subconscious bias and mistrust in relation to health
services (Johnstone and Kanitsaki, 2007; Smith and Betancourt, 2007).
27
7. GOVERNMENT POLICY AND REPORTING
FRAMEWORKS FOR CULTURAL DIVERSITY
This section will firstly map out the cultural diversity policy, planning and reporting
frameworks in the Victorian Department of Human Services. This will be followed by
a selected exploration of what other state and Commonwealth governments are
undertaking. The purpose of this section links to Objective 1, as set out in the
introduction of this literature review.
7.1. Mapping Cultural Diversity Policy, Planning and Reporting
Arrangements for Cultural Diversity
The Department of Human Services is the largest Victorian government department.
It is a complex agency with different areas of responsibility including health, housing,
disability, children, aged care and mental health. The large scale of the department
and the multiple service delivery areas within entails numerous linkages,
frameworks, policies, legislations and planning and reporting arrangements.
The department operates within the larger policy and legislative framework of the
Victorian Government (in addition to the Commonwealth). The broader policy context
for cultural diversity is primarily informed by the principles contained in following
Victorian legislation:




Equal Opportunity Act 1995 (currently under review);
Racial and Religious Tolerance Act 2001;
Multicultural Victoria Act 2004 and its proposed amendments; and
Charter of Human Rights and Responsibilities Act 2006.
The department implements programs and services consistent with the Growing
Victoria Together: A Vision for Victoria to 2010 which aims to achieve outcomes
relating to economic, social and environmental concerns. This document identifies
shared goals are a focus for setting government priorities and includes high-quality
accessible health and community services and a fairer society that reduces
disadvantage and respects diversity (http://www.growingvictoria.vic.gov.au).
The Victorian Government’s overarching multicultural affairs policy, Valuing Cultural
Diversity 2002, contains four themes:
 Valuing diversity
 Reducing inequality
 Encouraging participation
 Promoting the social, cultural and economic benefits of cultural diversity to all
Victorians.
The department and other Victorian government agencies report on achievements
against Victoria’s multicultural affairs policy each year as part of a whole-ofgovernment approach to multicultural affairs. This reporting is stipulated in the
Multicultural Victoria Act 2004 where government departments are required to report
annually to the Minister for Multicultural Affairs and parliament on their
28
achievements in the multicultural arena. The department of reports through the
Diversity Unit against the four broad themes listed above.
The objectives of the Departmental Plan 2008-09 are:






Building sustainable, well-managed and efficient human services
Providing timely and accessible human services
Improving human service safety and quality
Promoting least intrusive and earliest effective care
Strengthening the capacity of individuals, families and communities
Reducing inequalities through improving health and wellbeing, particularly for
disadvantaged people and communities.
The department has tried to address t cultural diversity by developing a
comprehensive Cultural Diversity Plan 2007-2008 which maps out actions against
particular objectives. In addition it has adopted a Language Services Policy (2005).
This policy recognises effective communication to be essential to the delivery of highquality services. It outlines the necessary requirements to enable people who cannot
speak English, or who speak limited English, to access professional interpreting and
translating services when making significant life decisions and where essential
information is being communicated
(http://www.dhs.vic.gov.au/multicultural/langservpolicy.htm).
In line with its multicultural affairs policy obligations, the department’s Diversity Unit
has developed a guide which establishes six strategy areas for improving cultural
responsiveness under a Cultural Diversity Guide (2006). The six areas are:
1.
2.
3.
4.
5.
6.
Understanding clients and their needs
Partnerships with multicultural and ethno-specific agencies
A culturally diverse workforce
Using language services to best effect
Encouraging participation in decision making
Promoting the benefits of a multicultural Victoria.
While cultural diversity principles are adopted by the department, it notes that
‘Victoria’s cultural diversity provides a significant challenge for the Department and
its funded agencies, in ensuring that Victorians from all backgrounds can enjoy
access to human services on an equal footing, and are treated with respect and
sensitivity’ (DHS, 2006:6). The department’s Cultural Diversity Guide points out that
the delivery of culturally responsive, equitable services is a core quality expectation
of the department programs and funded agencies.
The departmental planning and reporting for cultural diversity form the foundations
of the Cultural Diversity Plan 2007-2008 and incorporate the following:




Health Service Cultural Diversity Plan (HSCDP);
Disability Services Cultural and Linguistic Diversity Strategy;
Home and Community Care (HACC) Cultural Planning Strategy; and
Cultural Diversity Plan for Victoria’s Specialist Mental Health Services.
These will be visited briefly to provide an overview and to analyse the commonalities
and differences across these reporting areas:
29
Health Service Cultural Diversity Plan (HSCDP)
The Health Service Cultural Diversity Plan’s objective is to improve the quality of
service delivery and ensure that health services cater appropriately for culturally and
linguistically diverse communities (Department of Human Services, 2008). The
minimum reporting requirements identified in this plan are six areas under the
Cultural Diversity Plan and health services (hospitals) report against these.
Since 2006 every Victorian health service has had to establish a cultural diversity
committee; develop and implements a health service cultural diversity plan; lodge
the plan with the Director, Statewide Quality Branch and from 2007 onward every
service is required to report annually on the plan’s accomplishments. The minimum
reporting set out in the cultural diversity guide applies to the HSCDP and includes
reporting against areas including:






data
knowledge
skills
language
engagement
education.
Please see Appendix 1 for details of the minimum reporting requirements.
Disability Services Cultural and Linguistic Diversity Strategy
Based on The State Disability Plan 2002-2012 of the Victorian Government this
strategy is underpinned by a legislative framework which includes the Disability
Discrimination Act 1992 (Commonwealth), Equal Opportunity Act 1995 (Vic), The
Intellectually Disabled Person’s Services Act 1986 (Vic) and The Disability Services
Act 1991 (Vic). The purpose of the Strategy is to assist all disability support
providers to plan and deliver culturally appropriate disability supports. These
providers include government and non-government organisations that deliver
supports such as accommodation, day programs, case management, respite,
advocacy, information, support packages and recreation. There are standards for
service providers which are embedded strongly in planning and quality assurance
processes. The current Victorian Standards for Disability Services 1999 (the
‘Standards’) represent the minimum operational standards for government and nongovernment disability support services in Victoria. To ensure that the standards are
implemented by organisations, a number of strategies have been developed,
including:




Consumer assessment
Service delivery self assessment
Management self assessment
Development and implementation of quality plans.
The Disability Services Cultural and Linguistic Diversity Strategy was launched in
2004 and its objective is to meet the needs of people from culturally and
linguistically diverse backgrounds with a disability, their family and carers. The
Strategy is located within a more regulated framework and has a stronger legislative
and monitoring framework than HSCDP. However, there are similarities in the
planning and reporting frameworks for cultural diversity. These are based on the
30
original six principles identified in the Cultural Diversity Plan. The seven goals in the
Disability Services CALD Strategy are:







Understanding people and their needs
Encouraging participation in decision-making
Providing culturally relevant and accessible information
A culturally diverse workforce
Using language services to best effect
Meeting the specific needs of different communities
Promoting the benefits of a culturally diverse Victoria.
The mechanisms for planning, monitoring and implementing the CALD Strategy is
through integration into existing practices. The department is a partner to the
Commonwealth and State/Territory Disability Agreement (CSTDA). As part of this
agreement, the department’s Disability Services Division coordinates the Victorian
collection for the National Minimum Data Set. The requirement of this data collection
has changed from a single day snapshot approach to an ongoing full year collection.
Home and Community Care (HACC) Cultural Planning Strategy (CPS)
This strategy has been in place since 1997 and its overall objective is to increase the
responsiveness of HACC services to people from culturally and linguistically diverse
backgrounds who were identified as one of the five ‘special needs groups; within the
broader HACC target population under the Commonwealth Home and Community
Care Act 1985. The Act recognises that people from culturally and linguistically
diverse might experience difficulties in gaining access to HACC services.
The Victorian HACC program is supported by the HACC Program Manual which sets
out legislative and policy frameworks and covers issues of implementation. HACC
service delivery occurs within the National Quality Assurance Framework which
comprises the HACC National Service Standards, HACC Program National Service
Standards Instrument and Guidelines, Consumer Survey Instrument and Guidelines,
HACC Program National Complaints Policy and Statement of Rights and
Responsibilities.
As part of the Commonwealth State/Territory Disability Agreement, HACC Services
also has to undertake data collection for the National Minimum Data Set. The
Victorian HACC Cultural Planning Strategy is designed to be used by HACC service
providers to demonstrate and evaluate the provision of culturally appropriate
services to people from CALD backgrounds. It is supported by a number of tools and
resources such as Cultural Planning Tool guidelines and resources.
The Tool conforms to the National Service Standards and seven principles around
which planning takes place: Access; Cultural Relevance; Consultation; Information;
Special Needs Programs; Service Coordination and Accountability. These areas are
then supported by broad indicators. CPS requires HACC providers to develop and
submit HACC Cultural Action Plan each year. The department funds 14 HACC Equity
and Access Program (HEAP) projects based in community agencies. The ‘HEAP
workers’ resource the service providers and support them in the development of
Cultural Action Plans. Action on Disability within Ethnic Communities (ADEC) is
funded to play a coordination role for HEAP workers across Victoria.
31
Departmental regional offices are responsible for regional planning, monitoring of
funding agreements, ensuring Cultural Action Plans are submitted and overseeing
implementation more broadly. The Culturally Equitable Gateways Strategy was
initiated in 2003 as CALD communities were identified as being under-represented in
core HACC services in relation to their numbers. This Strategy was reviewed in 2007
and overall, it identified that the Strategy made a positive influence on participation
of CALD communities at the local government level. The HACC Cultural Planning
Strategy is currently being evaluated. This evaluation will determine future directions
for cultural planning in the development of HACC policy and service delivery.
Cultural Diversity Plan for Victoria’s Specialist Mental Health Services 20062010
This plan provides a framework for improving mental health services’ accessibility
and responsiveness to Victoria’s culturally and linguistically diverse communities. The
key strategies adopted in the plan are listed in Appendix 2.
The Victorian Government is a signatory to the National Mental Health Strategy
which is an agreement between the Commonwealth and State/territory
governments. The national initiatives implemented by Department of Human
Services include the National Standards for Mental Health Services and the National
Practice Standards for the Mental Health Workforce. These documents emphasise
the need for cultural sensitivity, as central to quality mental health care. The
Victorian Government has also endorsed the Framework for Implementation of the
National Mental Health Plan 2003-2008 which has four key approaches relevant to
culturally sensitive care: a population health approach acknowledging the influence
of migration experience and culture as risk and protective factors in mental health;
improving service responsiveness to cultural diversity; strengthening quality; and
fostering culturally inclusive research and innovation.
7.2 Discussion
The Victorian Government multicultural affairs policy framework shapes the internal
policies and strategies of the department. The Cultural Diversity Guide (2006)
provides the skeletal framework for planning and reporting. A number of
commonalities exist in each of the different cultural diversity planning and reporting
areas deriving from the Guide. These include: understanding clients’ needs; access
by culturally and linguistically diverse communities to services; responsiveness of
services to cultural diversity including issues of language services, cultural
sensitivity, appropriate workforce and recruitment and training; consumer
participation; and overall promotion of multiculturalism or a commitment to cultural
diversity values. The differences lie, not in the principles, but in operationalising the
planning and reporting processes. These are linked to a number of factors including:




historical developments of service provision or policy area within the department;
Commonwealth State Agreements and the presence of National Service
Standards;
legislative base which provides a compliance base or a self regulatory (nonmandatory) framework; and
internal and external resources available to services to support cultural diversity
planning and reporting processes.
32
It is clear from the above mapping processes that there are many complex reporting
and planning arrangements within the department and providers may see these as
onerous and time-consuming. The planning and reporting processes, while
attempting to ensure consideration of cultural diversity, can inadvertently lead to its
resentment and it being seen as just another task to be ticked off as being done.
Onerous processes can be a prohibitive factor in the continuous improvement cycle.
A comparative look at the differences in reporting within the department begs the
question of mandatory reporting against self assessment. The exploration of the
answers to this question is complicated and patchy. A consultation undertaken by the
department in 2003 identified major problems including: better access to
information; problems with cultural sensitivity of services; access to language
services; better workforce planning and stronger monitoring and reporting (DHS,
2004).
While this consultation precedes the adoption of The Disability Services Cultural and
Linguistic Diversity Strategy, it is instructive in that it points to problems relating to
implementation of cultural competence, reporting and monitoring in a field (that is,
disability services) that has long had mandatory processes.
Similarly in the mental health area, with legislative and mandatory reporting
arrangements and Service Standards, responsiveness of clinical and psychiatric
disability rehabilitation and support services were not responsive to needs of CALD
clients (Department of Human Services, 2006c). The HACC program, again with
National Service Standards and legislative framework identified that cultural
responsiveness and access was a major issue which led to further initiatives such as
The Culturally Equitable Gateways Strategy.
On the other hand, HSCDP does not have legislative and service standards in the
same way. While health service are assessed by the Australian Council on Health
Care Standards using the tool EQUiP 4 Accreditation standards and guidelines, there
is no mandatory elements relating to cultural diversity service standards. The
cultural diversity elements of EQUiP 4 are presented in a very broad manner 1.6.3.
The reporting against HSCDP has resulted in strong compliance although without a
mandatory base. Eighty-four out of 88 health services across Victoria submitted
plans to the Statewide Quality Branch relating cultural diversity outcomes
(Department of Human Services, 2008a:7). In a consultation held in 2007 by
department, four key issues were identified as problematic in these reporting
arrangements:




variation in the duration of HSCPDs ranging from 1-3 years;
practice and scope of cultural diversity committees;
variation in the level of detailing of strategies and actions; and
different approaches to cultural diversity responsiveness based on geographical
location (for example, metropolitan, regional or rural).
Additionally there is little or no research about CALD consumer experiences of health
services. Work has been commissioned to develop consumer participation indicators.
The Victorian Patient Satisfaction Monitor (VPSM) collates surveys regarding peoples’
experiences in health services through a questionnaire mechanism - this is offered in
a range of languages.
33
A forum to review Health Service Cultural Diversity Plans titled Present PracticeFuture Opportunities Forum endorsed the value of cultural diversity planning
processes as a way to keep the focus on CALD issues in health services. However at
this forum, numerous planning and reporting challenges and issues were identified.
The key findings were:

linking HSCPD with other strategic and management planning;

reframing the plans under patient safety and risk management and performance
management;

linking various cultural diversity planning processes;

clearer planning and reporting processes and who has responsibility for it,
communication processes within the health service;

Strategic planning timeframes (there should be a three or even five year plan not
just a one year plan);

need to know how to access to expertise,

need for sufficient support and resourcing in planning and reporting;

need for clarity about whose role it is to evaluate if improvements to be made;

need for feedback on reporting and planning;

no baseline data and a lack of consistent data and information sources within the
department, particularly that there is no baseline data;

challenges of a whole-of-organisation approach within a complex departmental
environment;

need for leadership on cultural diversity within the department senior executive
champions, needing to build the status of the issue within competing priorities;

better partnerships with community and internal sharing of information;

need for a model of consumer participation that works with CALD communities;

improvements in language services;

streamlining reporting arrangements with auditing and quality improvement
processes in the Department of Human Services;

benchmarking and setting standards;

difficulties of measuring outcomes; and

making staff training mandatory and the need for standards on training.
In this forum there was a call from practitioners for ‘mandating’ managers on
performance and reporting more effectively and with correct reporting processes on
cultural diversity outcomes, embedding cultural diversity within risk, accreditation
and quality systems, and legislating for language services. This indicates
dissatisfaction with existing reporting processes, casting doubt on self reporting and
the need to make planning and reporting more effective. Additionally there was a call
34
for indicators, standards and benchmarking to establish stronger systems to measure
progress and cultural diversity outcomes in more concrete way (Department of
Human Services, 2008a). The department has commissioned work to develop a
second set of consumer participation indicators under the ‘Doing it well vs., not for
us’ policy framework.
7.3 Selected Commonwealth and State Policies and Reporting
Frameworks
Information in relation to current systems for reporting disparities for minority
groups of health care consumers as they relate to health systems is very difficult to
locate in the Australian context. Systems of reporting vary from agency to agency
and across the states in Australia. A desk based literature review was not able to
adequately identify internal reporting arrangements as many evaluations and reports
are not made public. Searches were conducted in the web pages of the
Commonwealth and state government departments of health, human services and
multicultural affairs. Much of the multicultural affairs reporting is focused broadly on
the government achievements against their policies and is not specific enough.
Where examples have been found, they have been about one-off initiatives or
highlights of a promotional nature, making analysis of their effectiveness difficult.
A reference to reporting by health services was noted in the Action Plan for the Royal
Adelaide Hospital (2007-2010:13) which indicated that: Procedures would be
developed to respond to complaints by patients about staff who are culturally
insensitive or discriminatory. A measurement of this intervention would be that
procedures would be completed and published, and that reporting would be ongoing.
However, King et al (2008 pp. 251) noted that out of 501 hospitals surveyed in the
US in 2006 fewer than one in five hospitals that collected race/ethnicity information
used it to assess disparities in quality of care, health outcomes, or patient
satisfaction.
The following represents an attempt to map the current state of cultural diversity in
Australia in relation to health. Due to the absence of an appropriate evidence base
available in the public domain, the picture, at best, can be described as patchy and
incomplete. At present the New South Wales Health Department has published the
guide to Health Services for a Culturally Diverse Society: Implementation Plan. The
NSW Government and NSW Health point out that they are committed to ensuring
public health services meet the needs of all NSW residents, regardless of their
cultural origins or their English skills. The Plan is aimed at achieving three consumer
based outcomes and outline strategies for the achievement of these outcomes:




People of non-English speaking background are aware of the health services
which are available to them and the health system which provides these services.
People of non-English speaking background make judgements about the health
system and their own needs and articulate these to the appropriate
organisational component within the health system.
Judgements made by people of non-English speaking background about health
system and their own health needs are included in the policies and plans of the
health system.
Health systems services are accessible and appropriate and used by people of
non-English speaking background (NSW Health, 2002).
35
Information on the reporting mechanisms for these or what standards are used for
reporting was not identifiable from their public information systems.
In their website, NSW Health promotes:



policies and procedures to allow equal access for all people to health services;
programs and health services which recognise the cultural diversity of the people
of NSW; and
commitment to equal opportunities that reflect the cultural diversity of NSW.
All public health system employees are required to follow these guidelines that are
explained in the following documents:
1. Health Services for a Culturally Diverse Society: An Implementation Plan (1995);
2. Circular 94/10: Standard Procedures for the Use of Health Care Interpreters
(1994);
3. Strategic Directions in Refugee Health Care in NSW (1999);
4. Caring for Mental Health in a Multicultural Society: A Strategy for the Mental
Health Care of
5. People from Culturally and Linguistically Diverse Backgrounds (1998); and
6. Guidelines for the Production of Multilingual Health Resources by Area Health
Services, NSW Health Department and NGOs funded by NSW Health (2001).
The NSW reporting and monitoring of multicultural affairs takes place under the
Ethnic Affairs Priorities Statements (EAPS). These reports are whole-of-government
reporting on multicultural affairs and take place within four broad headings. These
reports highlight key initiatives and are often promotional in nature. The broad
criteria are not sufficient to gauge what indicators or standards are being used and it
cannot be considered a measurement tool. The NSW Health Plan has seven strategic
objectives including meeting consumer needs and developing their workforce. Annual
Report 2007 (pp.169-172) reflects an attention to cultural diversity
(http://www.health.nsw.gov.au/pubs/2007/pdf/AnnualReport_07.pdf).
The South Australian Government Department of Health identifies the notion of
‘cultural accountability’ in their Primary Health Care Policy Statement 2003-2007.
The Statement defines cultural accountability as responding to diversity by
recognising, respecting and being accountable to the unique cultural needs and
values of diverse populations. However there is no information on how this
accountability is implemented or monitored.
(http://www.health.sa.gov.au/Default.aspx?tabid=62)
In Western Australia (WA), the government has adopted a Substantive Equality
Framework which agencies have to report against. The policy framework set out a
key role for the public sector in addressing systemic discrimination by:



ensuring that policies respond to individual and communities’ different needs and
priorities;
providing services that meet the needs of different Indigenous and ethnic groups;
and
having effective work practices including recruitment and retention policies.
36
The WA Government reporting framework has been designed as an integral part of
the change process to:





enable agencies to make gradual transition towards the aims of the Policy
Framework for Substantive Equality;
develop the Policy Framework aims in a supportive and learning environment;
move away from the usual generic ‘one size fits all’ model of reporting, to one
which suits the individual needs of agencies;
make reporting easier; and
increase accountability in relation to providing services to people of different
Indigenous and ethnic backgrounds
(http://www.equalopportunity.wa.gov.au/pdf/summaryguide.pdf).
The interesting element of this model is that it does not implement a generic
framework across all agencies to report against. Rather outcomes are negotiated and
agencies report against those achievements they negotiated.
In Queensland, Queensland Health has been making progress towards embedding
cultural diversity into its service and program design and delivery. They have a
number of policy frameworks within their portfolio including:



Queensland Health Multicultural Policy Statement
Queensland Health Language Services Policy Statement
Queensland Health NESB Mental Health Policy Statement
These policies set out the principles of access and equitable health service delivery to
CALD communities.
The implementation framework is governed by a number of plans. The Statewide
Health Services Plan 07-12 recognises the health needs of people from CALD
backgrounds and identifies that improving access to health services will be
considered in Area Health Service and other planning processes. In addition, it has
developed the Queensland Health Strategic Plan for Multicultural Health 2007-2010.
The reporting on the cultural diversity planning takes place through the Queensland
Health Multicultural Action Plan 2006-2007 which is a whole of government process
on reporting on multicultural affairs. They identify a series of action that build
cultural competence of the health system such as:
 Focus on refugee health
 Workforce development
 Training of professionals
 Building sustainable language services
 Monitoring and evaluation strategies for particular program areas
 Raise Queensland Health’s profile in CALD communities
 Work on culturally appropriate complaints mechanisms
 Develop and disseminate a guide on information dissemination
 Establish a state-wide model of multicultural mental health coordinator positions
(http://www.health.qld.gov.au/multicultural/policies/ActionPlan_2006_07.pdf).
Queensland Health has established a multicultural health site and has identified a
five-year strategic plan with key actions against it. The reporting takes place against
four broad criteria of the Multicultural Queensland Policy. These are:
37
1.
2.
3.
4.
Strengthening Multiculturalism
Productive Diversity
Supporting Communities
Community Relations and Anti-Racism.
Since the election of the Rudd Labour Government, there has not been a review of
the policy framework for multiculturalism. The Department of Immigration and
Citizenship traditionally monitored and reported against access and equity
considerations. Between 1996 and 2005, the department published the Access and
Equity annual report, which reported on progress in implementing the Charter of
Public Service in a Culturally Diverse Society. In 2007, the Charter was replaced by a
new strategy, Accessible Government Services for All (AGSFA). This framework was
adopted to promote fairness and responsiveness in the design, delivery, monitoring
and evaluation of government services in a culturally diverse society. In 2008,
AGSFA reverted to the Access and Equity name; however, the strategy remains the
same. The reporting criteria for AGSFA are also broad and include:





Responsiveness—the extent to which programmes and services are accessible,
fair and responsive to the individual needs of clients.
Communication—the openness and effectiveness of communication channels with
all stakeholders.
Accountability—the effectiveness and transparency of reporting and review
mechanisms;
Leadership—a whole of government approach to management of issues arising
from Australia’s culturally and linguistically diverse society.
A number of strategies are suggested under each of these categories for
implementation and reporting.
(http://www.immi.gov.au/about/reports/accessible_government/accessible_gove
rnment_2006/_pdf/accessible_government_appendixa.pdf)
An examination of cultural competence performance reporting in Indigenous Affairs
shows other practices of planning and reporting. The Australian Health Ministers
Advisory Council (AHMAC) endorsed the National Cultural Respect Framework for
Aboriginal and Torres Strait Islander Health in 2004. This is guided by four broad
areas:




Knowledge and Awareness
Skilled Practice and Behaviour
Strong Customer or Community Relationships
Equity of Outcomes
This framework is useful in that it identifies areas of focus within organisational
performance related to culture.
Each jurisdiction is to develop its own reporting frameworks. For example, the
Western Australia Government Office of Aboriginal Health has developed a Cultural
Respect Framework which has four key parts:



An Aboriginal impact statement for policy and program development
Services reform through cultural partnerships, education, review and practice
development
Aboriginal workforce development
38

Monitoring and evaluation
Planning occurs through an impact statement rather than a generalised plan. In
terms of monitoring and evaluation the framework lists potential actions as:





Monitor use of the Aboriginal impact statement in program and policy proposals
at divisional, area health service and local level;
Monitor number of cultural partnerships, cultural education sessions and services
reviews by directorates and health services;
Assess trends in Aboriginal hospital admission data;
Conduct periodic Aboriginal patient satisfaction surveys;
Consult local Aboriginal community representatives on the cultural
appropriateness of local health services (Government of WA b).
Reporting and monitoring systems are complex and depend on many organisational
developments. Their effectiveness is dependent on factors on a number of factors
including: planning processes, resources, specificity of the criteria for performance,
utilisation of reports in improvements in service, policy and program development
and links to other accountability mechanisms. Bischoff (2003) identifies that it is
important to connect systems of reporting with quality of care. He identifies that
improving the quality of health care encompasses six aims: safety, effectiveness,
patient-centeredness, timeliness, efficiency and equity. Smith (2002) advocates that
monitoring for cultural diversity and migrant/minority health care issues require it to
be framed as a quality issue. A glance at current practice in Australia indicates that
what is happening is fragmented. Reporting frameworks often relate to the principles
relating to cultural diversity outlined above. None of these are specific enough to
determine measures of progress. This calls into question whether more specific
standards and indicators are needed.
The reporting process is also fraught with complications and these apply to the
department and other government agencies. The key issues include:






Lack of quality baseline data;
A lack of standard definitions complicates comparability between government
agencies and health services;
Multiple reporting processes, which are not well integrated;
Instruments of reporting often need to be reworked to address linguistic and
cultural issues, for example, separation of quality improvement, patient safety,
other risk management, patient satisfaction and other processes;
The impact of the intervention is often difficult to isolate from other factors;
The standards of data collection and assessment of impact are often
inappropriate (for example, randomized control trials).
Integrating cultural competence reporting into broader national health care
objectives, is a challenge but one that should be urgently addressed.
39
8. STANDARDS OF CULTURAL COMPETENCE FOR
HEALTH SERVICES
A lack of national standards exists in relation to the provision of culturally and
linguistically appropriate services in health services. This makes reporting
requirements within and between health departments difficult to ascertain, and to
measure progress against.
Anderson et al (2003) undertook a review of interventions that were designed to
take into consideration the health care needs of CALD clients, utilisation of services
and levels of satisfaction. They identified a number of strategies including:





recruitment and retention of CALD staff that reflect the diversity of client groups;
language services, particularly use of interpreters and/or bilingual providers;
use of linguistically and culturally appropriate health education materials;
training relating to cultural awareness and competence for health services; and
provision of culturally relevant healthcare settings.
The evaluation of outcomes of before-after or control group studies indicated
outcomes relating to improvement in client health status, client satisfaction with
care, improved service utilisation by CALD clients and changed treatment regimes for
CALD clients. However, the study did not find sufficient evidence to determine the
effectiveness of any of the interventions. This highlights the key questions for this
section poses a number of key questions:
1. What standards should be used?
2. What are the indicators?
3. How is progress against the standards and indicators to be measured?
Standards are published documents setting out specifications and procedures
designed to ensure products, services and systems are safe, reliable and consistently
perform the way they were intended to. They establish a common language which
defines quality and safety criteria (Standards Australia). They also establish
protection for consumers, provide opportunity for improvement and innovation and
can act as regulatory mechanism. Determining what outcomes have been achieved
against standards work well when they are aligned to indicators which are
appropriate to measure progress.
Standards, explicitly and by implication, set out the knowledge and skills that an
individual or an organisation must have to fulfil the requirements for standards of
performance. Standards can focus on different levels of the health care system: the
patient, the practitioner, the organisation, the region or the country. This is because
the conditions for error and harm can occur at all levels. Standards can work towards
mitigating risk and achieving quality outcomes.
The Lewin Group (2002) undertook a project with the aim to develop an analytical
framework for assessing cultural competence in health care delivery, identify specific
indicators, and assess the utility, feasibility and practical application of the
framework and its indicators. The resulting framework is named as a Cultural
Competence Assessment Profile (the Profile) that is a tangible and targeted approach
40
for conducting organisational assessments. It has three major components: a)
domains of cultural competence, b) focus areas within domains, and c) indicators
relating to focus areas. The domains include organisational values, governance,
planning and monitoring/evaluation, communication, staff development,
organisational infrastructure, and services/interventions; each domain has focus
areas and focus areas have indicators (for example, structure, process and output).
Key observations of this project are:



Assessment is Not an Isolated Event assessment of cultural competence should
not be considered an isolated event, but rather a continuous process that is
emphasized and integrated in an organisation’s overall assessment activities.
Importance of Assessing Institutionalisation: there is a need to assess the
‘institutionalisation’ of cultural competence in an organisation, that is, the extent
to which cultural competence is an integral part of the organisation’s service,
management and business functions.
Validation of the Components of the Profile: the exploratory process for this
project give credence to the Profile’s seven evidence-based domains as
appropriate performance areas for assessing cultural competence. The sites
emphasized the importance of assessing the domain of organisational values as
the necessary precursor to culturally competent performance. Since the
development of the Profile involved action research, the site visits supported the
credibility of the Profile’s focus areas and specific indicators.
The authors suggest the profile can assist organisations to identify the critical
elements of measuring cultural competence. It can also be used in structured quality
assurance and other performance measurement activities such as mandates and
standards. The profile can be useful to organisations serving a single and multiple
ethnic groups. In addition, it is potentially useful for organisations at different levels
of cultural competence development due to its flexibility organisations can pick and
choose aspects that most suit them.
8.1 Australian Standards
There are a number of standards that provide the framework for health and allied
health service provision in Australia. Commonly recognised providers of health care
standards and/or accreditation services include the Australian Council for Health Care
Standards (ACHS), the Quality Improvement Council (QIC) and the International
Organisation for Standardisation (ISO).
The Standards set by the Australian Council of Healthcare Standards
(ACHS).
ACHS’s mission is to ‘improve the quality and safety of health care’ through an
independent assessment process. The Evaluation and Quality Improvement Program
(EQUiP 4) provides a framework for safety and quality for health services. It is a selfassessment undertaken by health services on an annual basis with biennial on-site
surveys by external accreditation surveyors. EQUiP4 sets out standards in three
broad areas, namely, Clinical, Support and Corporate. These cover the standards
relating to continuity of care; access; appropriateness, effectiveness; safety and
41
consumer focus, quality improvement and risk management; human resource
management; information management; population health; research; leadership and
management; and safe practice and environment.
The standards are divided into mandatory and non-mandatory. There are 14
mandatory standards; none specify cultural diversity. Standards relating to cultural
diversity are listed under Consumer Focus (non-mandatory) in Article 1.6.3 which
states ‘The organisation makes provision for consumers / patients from culturally and
linguistically diverse backgrounds and consumers / patients with special needs.’
(http://www.achs.org.au/pdf/E4A3_poster.mandcriteria.pdf)
These standards are provided within a continuous improvement cycle of awareness,
implementation, evaluation, excellence and leadership. Some examples are provided
under each of these elements. The accompanying guide notes that health services
should develop policies and systems to address:





Understanding people and their needs
Systems to understand and analyse changing demographics
Providing relevant and accessible information
An appropriately trained workforce
Meeting the specific needs of different communities.
(http://www.achs.org.au/pdf/E4A3_poster.mandcriteria.pdf)
These standards are relevant to HSCDPs as they cover similar criteria about
culturally sensitive service provision. Implementation and reporting for HSCDPs can
be an important element of meeting accreditation requirements.
The National Standards for Mental Health Services outlines a standard which
specifically relates to cultural awareness. A standard on cultural awareness is that
‘the Mental Health Services (MHS) delivers non-discriminatory treatment and support
which are sensitive to the social and cultural values of the consumer and the
consumer’s family and community’
(http://www.health.vic.gov.au/mentalhealth/quality/national-standards.pdf, pp.25).







These standards are mandatory and have a specific reporting requirement as
noted above. There are a number of criteria listed for these standards:
MHS staff have knowledge about the social and cultural groups represented in the
defined community and an understanding of those social and historical factors
relevant to their current circumstances.
The MHS considers the needs and unique factors of social and cultural groups
represented in the defined community and involve these groups in the planning
and implementation of services.
The MHS delivers treatment and support in a manner which is sensitive to the
social and cultural beliefs, values and cultural practices of the consumer and their
carers.
The MHS employs staff or develops links with other service
providers/organisations with relevant experience in the provision of treatment
and support to the specific social and cultural groups represented in the defined
community.
The MHS monitors and addresses issues associated with social and cultural
prejudice in regard to its own staff.
Documented policies and procedures exist and are used to achieve the above
criteria.
42

The MHS monitors its performance in regard to the above criteria and utilizes
data collected to improve performance as part of a quality improvement process.
(http://www.health.vic.gov.au/mentalhealth/quality/national-standards.pdf)
A scan of the literature was not able to identify an evaluation of the practice of
implementation of these standards or their effectiveness for culturally sensitive care.
The Evaluation Report of the Second Mental Health Plan noted that there remains,
however, a continuing need to improve health outcomes for people from culturally
and linguistically diverse backgrounds.
The Standards for Disability Services in Victoria set out the expectations of better
practice for the delivery of services and supports to people with a disability. The
current Victorian Standards for Disability Services 1999 (the ‘Standards’) represent
the minimum operational standards for government and non-government disability
support services in Victoria. To ensure that the standards are implemented by
organisations, a number of strategies have been developed, including:




Consumer assessment
Service delivery self assessment
Management self assessment
Development and implementation of quality plans.
The HACC National Service Standards were introduced in 1991 to provide agencies
with a common reference point for internal quality controls by defining particular
aspects of service quality and expected outcomes for consumers in seven key areas:
1.
2.
3.
4.
5.
6.
7.
Access to Services
Information and Consultation
Efficient and Effective Management
Coordinated, Planned and Reliable Service Delivery
Privacy, Confidentiality and Access to Personal Information
Complaints and Disputes
Advocacy.
These standards are assessed by the HACC National Standards Instrument and
Guidelines covering the seven criteria listed above. The standards are assessed using
self assessment and joint assessment methodologies with the relevant State
Department.
The Instrument has a number of specific questions relating to cultural diversity:
Objective 1: How can your agency demonstrate that access to services by special
needs groups occurs on a non-discriminatory basis?
Objective 4: How does your agency ensure that the consumers’ cultural needs are
taken into account when providing care/support? (http://www.health.gov.au)
The guidelines are not meant to be prescriptive but rather are intended to provide
general guidance to agencies and service quality assessors in collecting the views of
consumers as part of the appraisal of service quality.
The Royal College of General Practitioners have developed standards for health
services in Australian detention centres. They identify that the criteria in these
Standards relate to systems and processes that require extra attention to ensure the
43
provision of high quality and safe care to patients within immigration detention
centres. These include:









Informed patient decision (Criterion 1.2.2)
Interpreter services (Criterion 1.2.3)
Clinical autonomy for medical, clinical and allied health staff (Criterion 1.4.2)
Continuity of comprehensive care (Criterion 1.5.1)
Continuity of the therapeutic relationship (Criterion 1.5.2)
Engaging with other services (Criterion 1.6.1)
Respectful and culturally appropriate care (Criterion 2.1.1)
Confidentiality and privacy of health information (Criterion 4.2.1)
Transfer of health information (Criterion 4.2.3). (http://www.racgp.org.au)
While the context of health service delivery in detention centres is very different
from the traditional health service environments, the issues identified in the report
are transferable to other CALD populations in relation to care delivery. A number of
standards are developed including:













Access to Care
Information about the health service;
Health promotion and prevention of disease;
Diagnoses and management of specific health problems;
Continuity of Care,
Coordination of care
Content of Patient Health Records
Collaborating with Patients
Safety and Quality
Education and Training
Service Management; Management of Health Information
Equipment for Comprehensive Care
Clinical Support Processes.
Of particular interest is the subset of Collaborating with Patients Standard (2.1.1.) is
respectful and culturally appropriate care. This standard has a set of indicators which
will be described in the next section. (http://www.racgp.org.au) While not linked
directly with health systems standards
The Aged Care Standards and Accreditation Agency is the body appointed by the
Department of Health and Ageing, under the Aged Care Act 1997, as the
accreditation body residential aged care facilities. There are a number of standards
specified in the accreditation of residential care facilities. Of interest is the standard
3, titled Resident Lifestyle. The standard defines the general principle of the standard
and lists 10 expected outcomes. Outcome 3.8 is Cultural and spiritual life - Individual
interests, customs, beliefs and cultural and ethnic backgrounds are valued and
fostered (http://www.accreditation.org.au/AccreditationStandards).
To assist the implementation of this standard the Department of Health and Ageing
has initiated a Program titled Partners in Culturally Appropriate Care (PICAC) to
ensure the special needs of older people from diverse cultural and linguistic
backgrounds are identified and addressed. One of the key elements of this is the
funding of the Centre for Cultural Diversity and Ageing which provides both
community support and service provider support
(http://www.culturaldiversity.com.au)
44
8.2 International standards
Culturally and Linguistically Appropriate Services (CLAS) are the US set of
recommendations for national standards with an outcomes-focused research agenda.
In 2001, the Department of Health and Human Services’ Office of Minority Health
(OMH) published standards for culturally and linguistically appropriate services for
healthcare organisations. These standards were an initial move to provide structure
to what constitutes culturally appropriate healthcare services. The CLAS standards
are proposed as one means to correct inequities that currently exist in the provision
of health services and to make these services more responsive to the individual
needs of all patients/consumers. 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.
There are 14 standards, (refer to Appendix 3 for details) which are organised by
themes:



Culturally Competent Care (Standards 1-3)
Language Access Services (Standards 4-7)
Organisational Supports for Cultural Competence (Standards 8-14).
Within this framework, there are three types of standards of varying stringency:



Mandates—CLAS mandates are current federal requirements for all recipients of
federal funds (Standards 4, 5, 6, and 7).
Guidelines—CLAS guidelines are activities recommended by OMH for adoption as
mandates by Federal, State, and national accrediting agencies (Standards 1, 2, 3,
8, 9, 10, 11, 12, and 13).
Recommendations—CLAS recommendations are suggested by OMH for voluntary
adoption by health care organisations (Standard 14).
(http://www.omhrc.gov/templates/).
In the submission to the CLAS standards a number of concerns were expressed by
different agencies relating to implementation and reporting. These considerations are
central to cultural competence practice and include a range of perspectives.
‘We do not believe that culturally and linguistically appropriate health care services
are an area of health care that should be highly regulated. When a guideline or
standard is strictly mandated and regulated, all possible opportunities for flexibility
and innovation are eliminated. This approach is not in the best interests of the
patient or customer needing the service.’
‘To have any effect in practice, finalised standards must be more than mere
‘guideposts.’ To the extent possible, the final standards should be issued as
enforceable regulations. Without an enforcement mechanism to support the final
standards, we fear many health care organisations and providers will not prioritize
linguistic and cultural competence and our communities will continue to lack access
to quality health care.’
45
‘The American Academy of Pediatrics agrees with the intent of the DHHS
recommendations for cultural competence standards. However, the Academy has
concerns regarding the availability of education, training, qualified personnel,
adequate reimbursement, evaluation mechanisms and other resources required to
implement and comply with the standards.’
‘Issues related to incentives, costs, reimbursement and other administrative
concerns and if CLAS standards are applied if applied literally, they would likely
overwhelm most hospitals’ and physicians’ resources — both time and money’ (US
Department of Health and Human Services 2001).
The implementation of CLAS has met with challenges. These are reflected in a
number of forums and documented in the Third National Conference on Quality
Health Care for Culturally Diverse Populations: Advancing Effective Health Care
through Systems Development, Data, and Measurement, 2002. The conference notes
that the two greatest challenges to implementing organisational cultural competence
strategies remain persuading leadership and staff, and finding resources. Integrating
cultural competence into broader organisational goals and programs was identified,
as the key strategy. The Conference resolved that the CLAS standards can guide
organisational change and assist with the implementation of cultural competence in a
host of health care settings. However, representatives of health care organisations—
clinics, hospitals, county health departments, and for-profit and nonprofit managed
care organisations—reported on several years of experience implementing cultural
competence activities. Gaining support for organisational change was identified as
‘very challenging’, but many Health Services felt that the national standards for CLAS
provided a useful guide the interventions they are implementing.
(http://www.diversityrx.org)
8.3 Discussion
As can be seen from these standards, cultural diversity is either not included or
included as a subset of other standards. Where it is included, the standard is very
broad and does not provide sufficient guide for agencies for implementation. While
some standards have guides or specified outcomes, these are not specific enough.
There are also a number of issues that arise from setting and implementation of
standards. It is assumed that standards setting results in compliance. The review
shows there are no accepted standards or method for reporting on safety and quality
in health care organisations.
The US Institute of Medicine (2001) Crossing the Quality Chasm notes that a system
is high quality if it provides care that does not vary because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic
status. Accreditation is, however, often accepted as providing an indicative measure
of quality. Also questions are raised about whether standards can, in reality, prevent
‘risk’ or guarantee the quality of care. As noted by the Australian Council for Safety
and Quality in Health Care (2003: 6) it should not be assumed that the higher the
standards set by standard-setting agencies the better compliance would be.
Whenever a standard is set, some organisations will decide that the costs of
compliance exceed the costs of non-compliance. In the various standards explored
above, the levels of compliance with the standards related to cultural diversity
remains unknown.
46
The expectation of stakeholders who are involved in the accreditation and standards
process means that there is more scrutiny of the standards and the expectation of
more efficient and streamlined systems to cater for diverse Health Services. In
relation to cultural competence in health care there is the debate on whether a
national framework should be developed and publicly reported each year against
standards and benchmarks.
The Australian Council for Safety and Quality in Health Care notes a number of issues
for consideration, especially in relation to accreditation and the standards that are
developed for accreditation purposes. The pertinent issues are categorised and
discussed below.
Standards development processes
There are a growing number of standards and standards setting bodies in health
care, raising concerns about the cost and quality of standards setting processes.
There is little coordination to prevent duplication of standards across organisations
and service delivery areas, as well as identification of new priority areas.
Accreditation agencies that develop their own standards fund that activity
(sometimes with ad hoc government assistance) through membership fees from
organisations that they will subsequently survey for accreditation. This may create
competing imperatives relating to the rigour of the standards versus the subsequent
cost of compliance to members.
There is a variable level of involvement of consumers or other independent
stakeholders in standards setting processes. Whether consumers should be involved
in the accreditation or assessment processes; what level of involvement should they
have are issues of contention. The Working Group strongly believes that consumers
should be involved at all levels including the governance structures of any
accreditation/assessment system.
Quality of standards
Defining a ‘safe health system’ is not an easy task and to date has not been done
sufficiently well. The underpinning philosophy of standards varies widely. For
example, some define minimum acceptable structures, processes or outcomes, while
others are goal oriented/ideal statements. Standards for health care have
traditionally focused on organisational structures and processes. They are moving
towards an outcome orientation but have not yet comprehensively addressed patient
safety. There is no single set of minimum or core standards for health care.
Accreditation processes
Whilst there are some incentives (including funding incentives), participation in
accreditation programs is largely voluntary. Informed consumers are concerned that
accreditation based on an organisation’s commitment to continuous quality
improvement may overlook the possible inadequacy of the starting point from which
improvement is being encouraged. There is little being learned by the health care
system from the wealth of data collected through the accreditation processes. There
is a variable level of involvement of consumers in accreditation or standards
development.
Organisational impact
There are strong imperatives to reduce the administrative burden of accreditation.
Stakeholders are concerned that accreditation is potentially diverting resources from
47
strategies aimed at directly addressing quality and safety concerns. There is
particular concern about requirements to be accredited by multiple service providers
against multiple sets of standards. In addition, the burden of accreditation on small
facilities may be disproportionate to their resources and capacity, and to the
outcomes gained from accreditation. In addition to requiring accreditation, most
state governments and some third party purchasers require evidence of compliance
with specific system and outcome criteria, creating a significant extra burden for
health care organisations. The question is whether a more robust accreditation
system could completely meet the requirements of these stakeholders, thereby
alleviating the administrative burdens created by their additional compliance and
reporting requirements. Organisations want a system that reassures the board,
management, consumers and clinicians that their facility is providing care of an
acceptable standard of safety and quality.
(http://www.aasw.asn.au/adobe/publications/mental/MH_Safety_quality.pdf).
The US National Quality Framework argues that cultural competence cannot alone
deliver outcomes unless it is embedded across all aspects of an organisation. One of
the conclusions of 2002 The Third National Conference on Quality Health Care for
Culturally Diverse Populations in relation to advancing effective health care through
systems development, data, and measurement was that cultural competence must
align its objectives with broader quality-of-care initiatives to strengthen its position
in the national health care agenda.
The implication of this is that cultural diversity issues need to be reconsidered as
part of a broader quality of care processes of the department including risk
management, patient centered care and appropriate data collection including
consumer feedback data
(http://www.diversityrx.org/CCCONF/02/PROCEEDINGS_0401.htm#03a).
The National Quality Framework also notes that a standardised core set of
performance measures based on cross-cutting quality issues that is broadly
applicable across all healthcare settings should be adopted (NQF, 2002).
48
9. INDICATORS AND ASSESSMENT TOOLS
Indicators are instruments which are used to measure or determine what is
happening over time, measure progress made or establish benchmarks for
judgement. Indicators are an important element of performance measurement to
strive for good practice and ensure continuous quality improvement. A social
indicator was defined by the Organisation for Economic Cooperation and
Development (OECD) as a ‘direct and valid statistical measure which monitors levels
and changes over time in a fundamental social concern’ (OECD, 1976:14). The OECD
uses social indicators for two purposes: first to describe social developments and
second to determine how effective society and government are in altering social
outcomes.
This is to be contrasted to indicators linked to performance management techniques
that measured achievements in terms of outputs and targets (Armstrong et al,
2002:3). The terms outcome and impact are often used interchangeably to denote
what is being measured. ‘Outcomes reflect the net effect of the program on the
target population. They show the impact the program has on the original problems or
identified need, who receives assistance, and the impact of the program on people’s
well-being’ (Department of Premier and Cabinet Victoria 1988:16).
Beneforti and Cunningham (2002) identify three types of indicators:



Program viability and sustainability indicators
Participation indicators
Outcome indicators
Program viability and sustainability indicators measure aspects of program
functioning including: turnover; funding levels and stability; community consultation
and support; involvement, employment and training of local people; succession
planning; adequacy of facilities and equipment; and access to these facilities and
equipment at critical times. These indicators enhance understanding of the processes
which can lead to positive outcomes (and therefore how they could be repeated).
Participation indicators provide a summary measure of community participation in
activity or initiative, and where relevant, the participation of target groups (for
example, women, adults, youth, and refugees). Outcome indicators provide insight
into changes in social areas more broadly.
The most comprehensive set of indicators to measure cultural competence has been
developed by the Lewin Group in 2002. The Health Resources and Services
Administration (HRSA) and the Office of Minority Health (OMH) commissioned the
Lewin Group to develop indicators of cultural competence. The resulting Assessment
Profile included the domains that provide the underlying construct of cultural
competence within a healthcare organisation, and the critical areas in which cultural
competence should be evident or manifest in an organisation.
The Assessment Profile had the following eight domains:
Organisational Values: An organisation’s perspective and attitudes with respect to
the worth and importance of cultural competence and its commitment to provide
culturally competent care.
49
Governance: The goal-setting, policy-making, and other oversight vehicles an
organisation uses to help ensure the delivery of culturally competent care.
Planning and Monitoring/Evaluation: The mechanisms and processes used for:
a) long and short-term policy, programmatic, and operational cultural competence
planning that is informed by external and internal consumers; and b) the systems
and activities needed to proactively track and assess an organisation’s level of
cultural competence.
Communication: The exchange of information between the organisation/providers
and the clients/population, and internally among staff, in ways that promote cultural
competence.
Staff Development: An organisation’s efforts to ensure staff and other service
providers have the requisite attitudes, knowledge and skills for delivering culturally
competent services.
Organisational Infrastructure: The organisational resources required to deliver or
facilitate delivery of culturally competent services.
Services/Interventions: An organisation’s delivery or facilitation of clinical, public
health, and health related services in a culturally competent manner.
These domains (refer to Appendix 4 for a further breakdown of these domains) may
be considered the dimensions in an agency to which standards can be set. These are
then measured by specific indicators which the Lewin Group divides these into four
types.
Structure Indicators are used to assess an organisation’s capability to support
cultural competence through adequate and appropriate settings, instrumentalities,
and infrastructure, including staffing, facilities and equipment, financial resources,
information systems, governance and administrative structures, and other features
related to the organisational context in which services are provided.
Process indicators are used to assess the content and quality of activities,
procedures, methods, and interventions in the practice of culturally competent care
and in support of such care.
Output indicators are used to assess immediate results of culturally competent
policies, procedures, and services that can lead to achieving positive outcomes.
Intermediate outcome indicators are used to assess the contribution of cultural
competence to the achievement of intermediate objectives relating to the provision
of care, the response to care, and the results of care.
The Lewin Group indicators have spawned the development of a range of indicators
by different organisations in different domains. For example, the Migrant Friendly
Hospitals used the following indicators to measure staff training and to measure how
staff are able to better handle cultural encounters (http://www.mfheu.net/public/files/mfh-summary.pdf):

Feasibility could be demonstrated for example, acceptability among staff varied in
the hospitals but altogether a total of 149 staff members participated.
50




Quality was operationalised in terms of the following dimensions: content,
structure, amount of training units, qualification of trainers, composition of
participating staff, management support, systematic needs assessment on the
department level, integration in ongoing quality assurance etc.
Effectiveness could be confirmed by improvement of staff’s self-rated awareness,
knowledge, skills and comfort level concerning cultural diversity issues, as well as
by increases in interest levels regarding cultural competence and in staff's selfrated ability to cope with work demands.
Cost-effectiveness: external training costs were low, but developmental costs
rather high, despite personal costs being mainly covered through voluntary work.
Sustainability: training was recognised as an effective way to equip staff with
important competencies and will be continued but modified in all participating
hospitals.
The Cultural Competency Standards and Self Assessment Tool Manual developed by
the Multicultural Forum of Mental Health Practitioners (2005:pp.s 6-10) also
developed broad standards and indicators, as outlined in the following table1.
Standard
Service planning
Collaboration with Key Stakeholders
Equitable Access to CALD people
1
Indicators
Strategic Business Plan demonstrates
commitment
Policy for ensuring delivery of culturally
appropriate services to all cultural groups in
the service region
Incorporated cultural competence principles in
its recruitment processes for all positions at
the service
Gazetted specialist multicultural liaison staff
position
CALD representation on all internal
committees
Staff representatives on various CALD
community organisations
Distributed information in English and in key
CALD languages
Ensured clinicians are aware of existing
alternative/complementary providers for
example traditional healers; and key
individuals in community to consult with
concerning religious beliefs influencing
treatment
Informed CALD consumers about their rights
and responsibilities in accessing and using
service
Promoted awareness of its programs in
appropriate languages and places
Developed policies and procedures to address
and accommodate culture-based needs of
CALD consumers
Accessed accredited interpreter services when
needed
Conducted assessment and diagnoses by
formally qualified and cultural competent
clinicians
Some indicators have been para-phrased for the sake of brevity.
51
Language Services Policy
Clinical cultural competence Training
CALD Consumer and Care Participation
Research and Development
Fiscal Support
The service has a Language Services Policy
Negotiated with Interpreter Service agency to
ensure accredited interpreters who are
trained in health issues and terminology
Used accredited mental health trained
interpreters when required
Provided staff training on use of interpreters
Sought to develop a staffing profile which
reflects the cultural diversity of the wider
community
Ensured all staff undergo the state-endorsed
clinical cultural competence training program
within the first 12 months of employment
Made available culturally validated
assessment instruments or tools
Incorporated cultural competence into staff
orientation and performance review
requirements
The service has consulted with CALD
consumers in the development of programs
Taken satisfaction survey of CALD clients
The service has an organisational culture
which promotes research and development to
trans-cultural health
Linked with external agencies that have
research focus on health of CALD
communities
Patient admission forms collect data
compatible with the definition of CALD
An annually updated profile of CALD
communities within its service region
Conducted research in collaboration or
independently to measure the needs of CALD
population in its region
The service has budgetary policies that
allocate resources and fiscal supports to
achieve organisational cultural competence
While these indicators are useful, they are not detailed enough to measure
outcomes. Rather they can lead to broad statements of progress without sufficiently
quantifying it. This area has been identified as a gap in the literature by many
(National Quality Forum, Brach and Fraser, 2002). A search of the literature did not
reveal any benchmarks, which is not surprising given the diversity of health care
delivery contexts.
Kumas Tan et al (2007) identified 54 different instruments designed to measure
cultural competence, (a list of some of the key ones is provided in Appendix 5). The
authors noted that many of the tools were related to cultural competence linked with
individual awareness, knowledge or individual failing. They concluded that
measurement tools are highly problematic due to definitions of what constitutes
cultural competence, difficulties with assessing power relations and structural
inequality and the assumption that developing awareness and knowledge around
cultural competence are sufficient to change behaviour.
The success of any indicator is based on a number of factors including:
52








Data and information collected
Systems of data collection established
Specificity of measures used
Time frames in which the monitoring takes place
Involvement of stakeholders in the evaluation process
Reliability and rigour of processes
Reporting systems (Beneforti and Cunningham, 2002; OECD, 1976)
Planning or project establishment (at the outset) linkages to the program
reporting (after or during implementation)
The Third National Conference on Quality Health Care for Culturally Diverse
Populations: Advancing Effective Health Care through Systems Development, Data,
and Measurement (2002) noted that assessment, measurement, and data collection
was an important but under-developed area of work. They pointed out that funders
and consumers want more detailed information about the quality and impact of
cultural competence programs, yet the task remains difficult due to the scarcity of
appropriate tools and resources as well as reluctance on the part of some providers
and health care organisations to participate in evaluation and data collection
activities. The challenges identified in developing appropriate measurement
indicators were identifies as:
Finding the balance between the fluid and dynamic nature of culture and cultural
competence and the concrete demands of measurement:





Managing the complexity that stems from multiple levels of analysis.
Balancing short-term versus longitudinal measurement.
Compensating for the frequent lack of baseline data, and minimizing the burden
of subsequent data collection.
Accurately weighing the impact of cultural competence interventions against
other factors.
Impressing on organisations the value of measurement, and securing the tools,
resources and expertise to conduct it.
(http://www.diversityrx.org/CCCONF/02/PROCEEDINGS_0401.htm - 03a)
It was also noted that a tension often arises between the goals of program
evaluation and the desire to produce outcomes data. Programs implementing cultural
competence interventions are often under pressure to demonstrate the impact of
interventions on different health measures when they are still struggling to
understand how best to run their programs and collect basic data on outputs.
Given the difficulty of performance measurement, cultural audits have also been put
forward as a way to measure progress. Inglehart and Quiney (1997) document an
attempt to conduct cultural audits within a school of dentistry. They conclude that:
…Conducting a cultural audit is difficult work, often discouraging and frustrating,
but always interesting and personally challenging. It must become an ongoing
effort for every organisational unit that prepares providers for their professional
lives in the next century of this country.
Finally, the value of indicators has been questioned and a model of organisational
transformation has been put forward as an alternative by Dreachslin (1999:427). He
states:
53
'...Diversity leadership entails re-visioning differences…consequently, no checklist
of concrete behaviorally-based performance indicators can ever fully capture the
essence of diversity leadership.'
The notion of organisational change management is noted above in the models of
cultural competence.
54
10. TOWARDS A FRAMEWORK OF CULTURAL
COMPETENCE ASSESSMENT
This literature review indicates there is ample work on models of cultural competence
and tools of assessment. Models of cultural competence need to be adopted,
implemented in a way that is integrally embedded in the other processes of the
organisation.
Cultural competence needs to be viewed at different levels on the continuum of
individual to systemic. Cultural competence is both a process (means) and an end.
Often the measurement is about looking at outcomes at the end, which often misses
the process. Therefore some indicators of the process can be less fixed or more
qualitative in nature.
The domains of assessment and reporting are important. The key headings emerging
from the literature that are very important are:

















Access to services;
Attitudinal change and non-discrimination;
Equitable utilisation of health services;
Removal of disparities in health outcomes;
Leadership;
Corporate Systems: policies, strategic plans, quality assurance, risk
management;
Processes: Streamlined processes, cultural competence embedded;
Communication: language services, multilingual material, use of interpreters,
bilingual staff, clinical communication competence with CALD consumers;
Clinical processes and procedures: reviewed through cultural diversity lens;
Care delivery and patient support: patient-centred care;
Workforce diversity and training: for example, cultural competence training,
formal certificates in cultural competence, bilingual staff;
Consumer participation: in a range of committees, not just cultural diversity
committee;
Partnerships and community engagement- with relevant stakeholders
Cultural resources and expertise;
Integrated data collection systems which can provide cultural data as a sub-set of
the whole for example, CALD patient satisfaction;
Appropriate research which feeds into quality improvement, service delivery,
consumer engagement; and
Accountability public reporting of cultural diversity issues in reports, consumer
participation in quality assurance processes and reporting.
GOOD PRACTICE EXAMPLE
The European project ‘Migrant-friendly hospitals’ (MFH), sponsored by the European
Commission, DG Health and Consumer Protection (SANCO) brought together
hospitals from 12 member states of the European Union, a scientific institution as
coordinator, experts, international organisations and networks. These partners
agreed to put migrant-friendly, culturally competent health care and health
promotion higher on the European health policy agenda and to support other
55
hospitals by compiling practical knowledge and instruments. To test the feasibility of
becoming a migrant-friendly and culturally competent organisation the project
implemented and evaluated three selected subprojects in European hospitals. Local
implementation was financed out of hospital funds, and the European benchmarking
process was resourced by the project. In 2004 recommendations were launched as
the ‘Amsterdam Declaration towards Migrant Friendly Hospitals in an ethno-culturally
diverse Europe.
The declaration identified a number of areas which hospitals needed to focus on in
making their organisations ‘migrant friendly’ which included:









Developing a migrant-friendly hospital is an investment in more individualised
and more person-oriented services for all patients and clients as well as their
families.
Building awareness of migrant population experiences and existing health
disparities and inequities, including those that are gender-related, leading to
changes in communication, organisational routines and resource allocations.
Focusing on ethno-cultural diversity implies the risk of stereotyping—but migrant
status, ethnic descent; cultural background and religious affiliation are just a few
of the many dimensions of the complexity of human beings.
Developing partnerships with local community organisations and advocacy groups
who are knowledgeable about migrant and minority ethnic group issues is an
important step that can facilitate the development of a more culturally and
linguistically appropriate service delivery system.
Ensuring that hospital owners and management put quality of services for
migrants and ethnic minorities on the organisational agenda.
Ensuring that users (actual and potential patients, relatives), representatives of
community groups, patient organisations and community groups put diversity
and health and health care on their respective agendas.
Getting staff in health professions, hospitals and professional organisations to
acknowledge that the issues are relevant and being prepared to invest in
achieving competence.
Health policy and administration to provide a framework to make migrant-friendly
quality development relevant and feasible for each hospital (legal, financial, and
organisational regulations).
Health sciences through moving diversity issues in health and health care higher
up on their agendas, by including them in their theory-building and the
development of systematic evidence, health science disciplines can make
important contributions. Ethnic and migrant background information should be
included as a relevant category in epidemiological, socio-behavioural, clinical,
health service and health system research. (http://www.mfh-eu.net)
An important recommendation from this Declaration is the need to define what
cultural competence means. However, rather than generic criteria they note that, as
a first step, each service needs ‘to find consensus on criteria for migrantfriendliness/cultural competence/ diversity competence adapted to their specific
situation and to integrate them into professional standards and enforce that they are
realised in everyday practice’ (Amsterdam Declaration, http://www.mfh-eu.net).
There was a pilot program undertaken with 12 hospitals across Europe which began
in 2002. A Migrant Friendly Quality Questionnaire (MFQQ) tool was developed and
implemented across the 12 hospitals to assess how friendly hospitals were to
immigrants. The MFQQ proved useful in systematically assessing migrant-friendly
56
structures such as interpreting services, information material for migrant patients,
culturally sensitive services (religion, food), as well as components of a (quality)
management system to enable and assure the migrant-friendliness of services.
The six problem areas were identified as: language and communication, culturally
appropriate patient information and education, cultural barriers/lack of cultural
competencies, family visits, lack of culturally appropriate food and spirituality and
social support. Three project areas were selected to be worked upon:



Improving interpreting services
Migrant-friendly information and training for mother and child care
Staff training towards cultural competence.
A major strategy to test the feasibility of becoming a migrant-friendly and culturally
competent organisation was the implementation and evaluation of evidence and
experience-based interventions in these three specific areas.
An initial assessment in 2003 showed a heterogeneous European hospital group, with
some hospitals listing, many existing migrant-friendly services and a well-established
management structure in place, but with other hospitals showing considerable areas
for further development.
The results after one year of work within the European project showed that the
majority of hospitals could use the project for considerable improvements both on
the level of services as well as for developing their quality management systems
(http://www.mfh-eu.net/public/files/mfh-summary.pdf).
While the project summary states that experiences and results were presented at the
Final Conference ‘Hospitals in a Culturally Diverse Europe’ in Amsterdam, Dec 9-11,
2004, a search of the conference proceedings did not yield sufficient detail of the
evaluation of the project.
57
11. CONCLUSION
It is evident from this review that in Australia much has been achieved at the
Commonwealth and state levels in terms of recognition of the challenges faced by
culturally and linguistically diverse populations and health services. However cultural
competence practice in health settings is problematic and implementation and
reporting are fragmented.
It has been noted in this document that addressing discrimination at the personal
level is not straight forward as it often reflects broader community and organisational
norms. Strategies therefore targeted to individuals are more likely to be effective
when they are implemented alongside those aimed at building community,
organisational and societal environments that promote and respect diversity. This
can be further supported by developing culturally sensitive practice such as that
being undertaken in the Migrant Friendly Hospital project or in the United States to
measure CLAS outcomes.
From this literature review it is noted that there are significant challenges in the
implementation and reporting of cultural competence. These include:







Precise definitions of what is meant by cultural competence;
Integration of cultural competence initiatives with allied health practices such as
quality improvement, standards and accreditation, quality of care, risk
management and safety systems;
Leadership for organisational change to implement cultural competence;
Streamlining reporting processes;
Appropriate consumer participation;
Context specific benchmarks and indicators; and
Appropriate resources for cultural competence initiatives.
Creating cultural competence requires a shift in thinking as well as practice. NHMRC
(2005) points out mandatory measures need to be supported by initiatives that
promote good governance and reward change. An approach that combines
mandatory measures with incentives for improvement includes:







Strong accountability mechanisms;
Ensuring performance against these mechanisms;
Persuasive leadership for change at senior levels across the sector;
Applying existing tools and initiatives to create cultural competence for example,
risk assessment/management, continuous improvement cycles, triple bottom line
reporting, safety and quality initiatives;
Systematic change management strategies;
An evidence base built on culturally competent research that can inform policy,
planning, education and capacity building, and evaluation; and
Measures to build a culturally competent workforce.
Health organisations, policy makers and planners need to seek data, develop
infrastructure, set achievable short, medium and long-term goals and use business
best-practice tools to achieve sustained cultural responsiveness. Future directions in
the work relating to cultural competence must pay attention to the lack of consistent
58
definition and framework, strategies to making it integral to the operation of the
agency and appropriate measurement indicators of progress.
59
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RESOURCES
Appendix 1
Minimum Reporting Requirements Under HSCDP
The six areas detailed in the HSCDP are:
Understanding clients and their needs
Data: Accurately gathering a range of information pertinent to the CALD client group
will better assist your service to effectively respond to their needs through strategic
and targeted planning.
 Does current data collection adequately map the CALD client profile?
 Does current data inform the development of policy, strategies and service
delivery?
Partnerships with multicultural and ethno-specific agencies
Knowledge: Working in partnership with ethno-specific and multicultural
organisations can assist your health agency to develop a better understanding of the
dynamics of the CALD community in your area, and result in better service delivery
outcomes for your health service and CALD client group.
 What initiatives could benefit from a partnership with local CALD communities?
 Are the community groups and agencies the health service works with reflective
of the diverse groups in and around the health organisation?
A culturally diverse workforce
Skills: Employing staff with a range of culturally appropriate competencies will better
equip your service to respond to CALD issues and clients, and result in a more
culturally responsive workforce.
 Do recruitment methods include strategies to reach out to local communities?
 Does the human resources department have a system to report diversity
awareness progress to the board?
Using languages to best effect
Language: The effective management, provision and reporting of interpreting and
translating services is vital to improve access and communication to services for
persons with low proficiency in English.
 Are there organisational policies on when to use language services?
 Are there organisational procedures on accessing language services?
 Does the current range of translations reflect community language groups?
 Is the organisational information available in plain English?
Encouraging participation in decision-making
Engagement: Encouraging individuals and organisations to formally take part in the
health service’s decision-making process will lead to better service and planning
outcomes for your health service and CALD clients.
 Does the organisation consider CALD representation in the formation of its
committees and working groups?
68



Promoting the benefits of a Victoria Education: Promoting diversity and its
benefits will result in a more responsive workforce and lead to increased health
benefits for the community, of which the CALD clients group is an integral part.
Is diversity awareness and cultural competence training required for all
leadership positions and staff?
Is the organisational diversity reflected in the mission and values statement, and
visible to staff and the public?
Source: http://www.health.vic.gov.au/cald/downloads/cultural_diversity_plans.pdf
69
Appendix 2
Core Strategies of the Cultural diversity plan for Victoria’s specialist
mental health services 2006–2010






Culturally competent practice within mental health services and recognition of
this as a core skill required of staff.
Action by mental health services to understand the needs of local ethnic
communities, consumers and carers and to incorporate these perspectives into
service and workforce planning.
Action to address the barriers to the appropriate use of language services
(interpreting and translating) in mental health settings.
Action to address the specific mental health needs of refugees.
Mental health involvement and representation in government initiatives to
improve the wellbeing of culturally and linguistically diverse communities and
address barriers to appropriate use of mental health services.
Stronger government mechanisms for monitoring mental health services’
accessibility and responsiveness to culturally and linguistically diverse
communities.
Source: http://www.health.vic.gov.au/mentalhealth/cald/cald-strategy.pdf
70
Appendix 3
Culturally and Linguistically Appropriate Services and Standards
(USA)
1. Health care organisations should ensure that patients/consumers receive from all
staff members effective, understandable, and respectful care that is provided in a
manner compatible with their cultural health beliefs and practices and preferred
language.
2. Health care organisations should implement strategies to recruit, retain, and
promote at all levels of the organisation a diverse staff and leadership that are
representative of the demographic characteristics of the service area.
3. Health care organisations should ensure that staff at all levels and across all
disciplines receive ongoing education and training in culturally and linguistically
appropriate service delivery.
4. Health care organisations must offer and provide language assistance services,
including bilingual staff and interpreter services, at no cost to each
patient/consumer with limited English proficiency (LEP) at all points of contact, in
a timely manner during all hours of operation.
5. Health care organisations must provide to patients/consumers in their preferred
language both verbal offers and written notices informing them of their right to
receive language assistance services.
6. Health care organisations must assure the competence of language assistance
provided to limited English proficient patients/consumers by interpreters and
bilingual staff. Family and friends should not be used to provide interpreting
services (except on request by the patient/ consumer).
7. Health care organisations must make available easily understood patient related
materials and signposting in the languages of the commonly encountered groups
and/or groups represented in the service area.
8. Health care organisations should develop, implement, and promote a written
strategic plan that outlines clear goals, policies, operational plans, and
management accountability/oversight mechanisms to provide culturally and
linguistically appropriate services.
9. Health care organisations should conduct initial and ongoing organisational selfassessments of CLAS-related activities and are encouraged to integrate cultural
and linguistic competence-related measures into their internal audits,
performance improvement programs, patient satisfaction assessments, and
outcomes-based evaluations.
10. Health care organisations should ensure that data on the individual
patient's/consumer's race, ethnicity, and spoken and written language are
collected in health records, integrated into the organisation's management
information systems, and periodically updated.
11. Health care organisations should maintain a current demographic, cultural, and
epidemiological profile of the community as well as a needs assessment to
accurately plan for and implement services that respond to the cultural and
linguistic characteristics of the service area.
12. Health care organisations should develop participatory, collaborative partnerships
with communities and utilise a variety of formal and informal mechanisms to
facilitate community and patient/ consumer involvement in designing and
implementing CLAS-related activities.
13. Health care organisations should ensure that conflict and grievance resolution
processes are culturally and linguistically sensitive and capable of identifying,
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preventing, and resolving cross-cultural conflicts or complaints by
patients/consumers.
14. Health care organisations are encouraged to regularly make available to the
public information about their progress and successful innovations in
implementing the CLAS standards and to provide public notice in their
communities about the availability of this information
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Appendix 4
Lewin Group Cultural Competence Domains (2002)
Organisational Values: An organisation’s perspective and attitudes regarding the
worth and importance of cultural competence, and its commitment to providing
culturally competent care pertaining to:
 Leadership, Investment and Documentation
 Information/Data Relevant to Cultural Competence
 Organisational Flexibility.
Governance: The goal setting, policy-making, and other organisational vehicles to
help ensure the delivery of culturally competent care:
 Community Involvement and Accountability
 Board Development
 Policies.
Planning Monitoring and Evaluation: The mechanisms and processes used for:
 Long and Short-term Policy, Programmatic, and Operational Cultural Competence
Planning Informed by External and Internal consumers
 The Systems and Activities Required to Proactively Track and Assess
Organisational Cultural Competence
 Client, Community and Staff Input
 Plans and Implementation
 Collection and Use of Cultural Competence-Related Information/Data.
Communication: The exchange of information between the organisation/providers
and the clients/population, and internally among staff, in ways that promote cultural
competence.
 Understanding of Different Communication Needs and Styles of Client Population
 Culturally Competent Oral Communication
 Culturally Competent Written/Other Communication
 Communication with Community
 Intra-Organisational Communication.
Staff Development: An organisation’s efforts to ensure staff and other service
providers have the requisite attitudes, knowledge and skills for delivering culturally
competent services:
 Training Commitment
 Training Content
 Staff Performance indicators.
Organisational Infrastructure: The organisational resources required to deliver or
facilitate delivery of culturally competent services:
 Financial/Budgetary
 Staffing
 Technology
 Physical Facility/Environment
 Linkages.
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Services and Interventions: An organisation’s delivery or facilitation of clinical, public
health, and health related services in a culturally competent manner:
 Client/Family/Community Input
 Screening/Assessment/Care Planning
 Treatment/Follow-up.
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Appendix 5
Cultural Competence Assessment Tools
Source: http://www.transculturalcare.net/assessment-tools.htm
■ Inventory for Assessing the Process of Cultural Competence Among Healthcare
Professionals-Revised (IAPCC-R©) – Developed by Campinha-Bacote (2002), the
IAPCC-R is based on her model of cultural competence, The Process of Cultural
Competence in the Delivery of Healthcare Services (1998) and measures the five
constructs of this model (cultural desire, cultural awareness, cultural knowledge,
cultural skill and cultural encounters). Studies were conducted with a variety of
healthcare professionals and reliability scores ranged from a Cronbach's alpha of
0.72-0.90. This tool has also been translated into several languages and used
internationally. Click onto the following link for more details of studies using this tool.
■ Inventory for Assessing the Process of Cultural Competence Among Healthcare
Professionals-Student Version (IAPCC-SV©) – Developed by Campinha-Bacote
(2007), the IAPCC-SV© is based on the Inventory for Assessing the Process of
Cultural Competence Among Healthcare Professionals-Revised (IAPCC-R©). Vito,
Roszkowski, and Wieland (2005) noted in a study of 695 student nurses that the
IAPCC-SV© could be further revised resulting in a higher reliability of this tool. The
IAPCC-SV© is a result of modifying the response format of the IAPCC-R© to reflect
only responses of strongly agree, agree, disagree, strongly disagree and modifying
and deleting selected questions on the IAPCC-R©. Fitzgerald, Cronin and CampinhaBacote (2007) conducted a study entitled, Psychometric Testing of a Proposed
Student Version of the Tool, ‘Inventory for Assessing the Process of Cultural
Competence Among Healthcare Professionals-Revised’ in which they administered
the IAPCC-SV© to 91undergraduate nursing students at Bellarmine University
Lansing School of Nursing and Health Sciences to establish reliability of this tool.
Reliability testing revealed a Cronbach's alpha of .783. Click onto the following link
for more details of this tool.
■ Cultural Diversity Questionnaire For Nurse Educators – Developed by Lorinda
Sealey (2003), this fifty-five item tool includes statements developed by this
researcher, as well as items adapted from Campinha-Bacote's tool (IAPCC-R). This
tool also consists of items adapted from research conducted by Goode, Mason and
Ward. The Cultural Diversity Questionnaire For Nurse Educators is based on
Campinha-Bacote's model of cultural competence and includes items related to
cultural awareness, cultural knowledge, cultural skill, cultural encounters, and
cultural desire. Research on the tool is published in the following citation: Sealey, L.,
Burnett, M. and Johnson, G. (2006). Cultural Competence of Baccalaureate Nursing
Faculty: Are We Up to the Task? Journal of Cultural Diversity, 13(1), 131-140.
Contact: lsealey@selu.edu
http://etd.lsu.edu/docs/available/etd-1112103-133929/unrestricted/Sealey_dis.pdf
■ Blueprint for Integration of Cultural Competence in the Curriculum Questionnaire
(BICCCQ) –The 31-item BICCCQ was developed at the University of Pennsylvania,
School of Nursing, to measure student reports of components of content on cultural
competence taught in undergraduate and graduate nursing programs. BICCCQ items
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were derived from the Tool for Assessing Cultural Competence Training, which was
developed to measure faculty report of components of content on cultural
competence in medical school curricula. Cronbach's alpha ranged from .73 to .94
across factors and was .96 overall. Citation: Tulman, L. and Watts, R. (2008).
Development and testing of the Blueprint for Integration of Cultural Competence in
the Curriculum Questionnaire. Journal of Professional Nursing, 24(3), 161-166.
■ Cultural competence Organisational Assessment – 360 (COA360) – The COA360 is
an instrument designed to appraise a healthcare organisation's cultural competence.
The Office of Minority Health and the Joint Commission have each developed
standards for measuring the cultural competence of organisations. The COA360 is
designed to assess adherence to both of these sets of standards. Citation: LaVeist,
T., Relosa, R. and Sawaya, N. (2008). The COA360: A Tool for Assessing the Cultural
competence of Healthcare Organisations. Journal of Healthcare Management,
53(4):257-66; discussion 266-267.
■ Transcultural and International Nursing Knowledge Inventory (TINKI) – Baldonado
et al (1998) developed the TINKI, which is a questionnaire that includes closed and
open-ended questions related to participant's experiences in providing cultural care.
Citation: Baldonado, A., Ludwig Beymer, P., Barnes, K., Starsiak, D., Nemivant, E.
and Anonas-Ternate A. Transcultural Nursing Practice Described by Registered
Nurses and Baccalaureate Nursing Students. Journal of Transcultural Nursing, 9: 1525.
■ Cross-Cultural Evaluation Tool – The Cross-Cultural Evaluation Tool was developed
by Freeman. It is a five-point likert-type scale which measures a student's ability to
make culturally sensitive choices. Hughes and Hood (2007) published an article
which presents the psychometric properties of the Cross-Cultural Evaluation Tool that
yields a cross-cultural interaction score. Citation: Hughes, K. and Hood, L. (2007).
Teaching Methods and an Outcome Tool For Measuring Cultural Sensitivity in
Undergraduate Nursing Students. Journal of Transcultural Nursing, 18:57-62.
■ Cultural Competence Assessment (CCA) – Schim and colleagues developed the CCA
instrument, which is designed to measure cultural diversity experience, awareness
and sensitivity, and competence behaviors among health services and staff. Research
on the tool is published in the following citation: Schim, S., Doorenbos, A., Miller, J.
and Benkert, R. (2003). Development of a Cultural Competence Assessment
instrument. Journal of Nursing Measurement 11(1):29-40.
■ Infant/Toddler Caregiver Cultural Rating Scale (ITCCRS) - Based on Sue's (1981)
tri-dimensional model, the ITCCRS was created to assess 109 child care providers'
cultural competence and the demographic correlates of that competence. Subjects
were from 30 randomly selected infant/toddler centers that were licensed to provide
child care. The ITCCRS consists of 40-items; 10 items assessing awareness; 19
measuring knowledge, and 11 measuring skills. Obegi, A. and Ritblat, S. (2005).
Cultural Competence in Infant/Toddler Caregivers: Application of a Tri-Dimensional
Model. Journal of Research in Childhood Education, 19(3), 199-213.
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■ Miville-Guzman Universality-Diversity Scale (M-GUDS) – This is a 45-item
questionnaire rated on a 6-point Likert-type scale ranging from strongly agree to
strongly disagree. This scale is based on the theoretical model called the UniversalDiverse Orientation (Fuertes, Miville, Mohr, Sedlaki, and Gretchen, 2000), which
emphasizes an ability to tolerate similarities and differences between one's self and
another. The scale's three subscales are diversity of contact, relativistic appreciation,
and comfort with differences. This scale makes the theoretical leap that tolerance of
difference is key to intercultural work and cultural competence. Citation: Fuertes, J.
N., Miville, M. L., Mohr, J. J., Sedlacek, W. E., and Gretchen, D. (2000). Factor
structure and short form of the Miville-Guzman Universality-Diversity Scale.
Measurement and Evaluation in Counselling and Development, 33, 157-169.
■ Tailoring Initiatives to Meet the Needs of Diverse Populations: A Self-Assessment
Tool – A self-assessment tool is provided in Chapter 8 of One Size Does Not Fit All:
Meeting the Health Care Needs of Diverse Populations to help organisations evaluate
the way they currently provide care and services to diverse patient populations. The
questions are designed to promote discussion around the need to improve or expand
current initiatives to meet patients’ cultural and language (CandL) needs.
■ Cultural Awareness Scale (CAS) – Developed by Rew, Becker, Cookston,
Khosropour, and Martinez (2003) to measure the multidimensional nature of cultural
awareness in nursing students. The authors identified five key categories of cultural
awareness, based on a review of the literature, and developed scale items in each of
these categories: (1) general educational experience; (2) cognitive awareness; (3)
research issues; (4) behaviours/comfort with interactions; and (5) patient
care/clinical issues. Rew, L., Becker, H., Cookston, J., Khosropour, S., and Martinez,
S. (2003). Measuring Cultural Awareness in Nursing Students. Journal of Nursing
Education, 42 (6), 249-257.
■ Sociocultural Attitudes in Medicine Inventory (SAMI) - Developed by Tang et al, this
26-item 5-point Likert scale tool measures attitudes toward sociocultural issues in
medicine and patient care. Tang, T., Fantone, J., Bozynski, M. and Adams, B. (2002).
Implementation and Evaluation of an Undergraduate Sociocultural Medicine Program.
Academic Medicine, 77(6),578-585.
■ Transcultural Self-Efficacy Tool (TSET) – Developed by Jeffreys (2000), this tool is
designed to measure the degree of cultural self-efficacy among nursing students.
According to the tool’s authors, transcultural self-efficacy refers to perceived
confidence in performing or learning transcultural skills. The TSET consists of 83
items, conceptually based on the literature of transcultural nursing, ordered into
three subscales: (1) Cognitive (knowledge, consisting of 25 items); (2) Practical
(interview, consisting of 28 items); and (3) Affective (Values, attitudes and beliefs,
consisting of 30 items).
■ Tucker-Culturally Sensitive Health Care Inventories (T-CSHCI) – Tucker has
developed three race/ethnicity-specific forms of the T-CSHCI (one each for African
Americans, Hispanics and non-Hispanic whites) to be used by patients at communitybased primary care centers to evaluate the level of patient-centered cultural
sensitivity perceived in the health care that they experience. The T-CSHCI Patient
Form: a) are for patient use by patients; b) assess specific provider and office staff
behaviours and attitudes and healthcare center policies and physical characteristics;
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c) emphasize assessment of cultural-specific interpersonal behaviours; and d) consist
of items generated by low-income racial/ethnic minority and majority patients.
Citation: Tucker, C., Mirsu-Paun, A., van der Berg, J., Ferdinand, L., Jones, J., Curry,
R., Rooks, L., Walker, T., Beato. (2007). Assessments for Measuring PatientCentered Cultural Sensitivity in Community-Based Primary Care Clinics. Journal of
the National Medical Association, 99(6), 609-619.
http://www.nmanet.org/images/uploads/Publications/OC609.pdf. Based on Tucker's
Patient-Center Culturally Sensitive (PC-CS) Health Care Model, she has also
developed the T-CSHCI Provider Form and the T-CSHCI Staff Form. Please visit Dr.
Carolyn Tucker's home page at:
http://www.psych.ufl.edu/~tucker/BMED/BMED%20about.htm
■ Competence Continuum (CCC) – Based on Cross's (1989) Cultural Competence
Continuum Model of the 6 stages of cultural competence along a continuum, Wong
converted this conceptual model (CCC) to an ordinal scale to assess behavior in
cultural interactions revealed in reflective student writing. This tool s based on the
premise that students' reflective writing can be analysed using the CCC to reliably
and objectively assess the degree of cultural competence revealed in specific cultural
interactions. This behavioural assessment of cultural competence may provide a
method for providing feedback aimed at professional development in the area of
cultural competence for students, clinicians, faculty, and programs. Christopher
Wong is director of physical therapy programs at Touro College, 27 West 23rd
Street, New York, NY 10010 (ckwong@touro.edu).
■ Intercultural Development Inventory (IDI) – The IDI was designed by Bennett and
Hammer and measures how a person or a group of people tend to think and feel
about cultural difference. The IDI is based on Bennett’s Developmental Model of
Intercultural Sensitivity. Citation: Hammer, M. R., Bennett, M. J., and Wiseman, R.
(2003). Measuring intercultural competence: The Intercultural Development
Inventory. International Journal of Intercultural Relations. 27(4), ppp.421-443.
■ Cross-Cultural Adaptability Inventory (CCAI) – Developed by Kelly and Meyers
(1993) to help participants understand the qualities that enhance cross-cultural
effectiveness, become self-aware, decide whether to work in a culturally diverse
company and whether to live abroad, and to prepare to enter another culture. The
CCAI measures the 4 variables of emotional resistance, flexibility and openness,
perceptual acuity, and personal autonomy. (Intercultural Press - 1-800-370-2665).
■ Cultural Bases of Health Survey (CBHS) – The CBHS instrument consists of three
close-ended and one open-ended demographic questions; 35 close-ended, Likertscale cultural competence questions; and one open-ended clinical case vignette
question. This instrument is a result of the’ Seeing the Body Elsewise: Connecting
the Pre-Health Sciences and the Humanities grant project of the University of
Michigan's Program in Culture, Health, and Medicine. The aim of this grant was to
rethink ways cultural diversity is taught in pre-health education. The project included
an interdisciplinary model for teaching pre-health undergraduate students (premedicine, pre-nursing, pre-life sciences) about the intersections of race, gender,
health, and ethnicity. The CBHS is one of the project’s evaluation activities. For more
information contact Dr. Piontek at mpiontek@umich.edu or visit
http://c2003.evaluationcanada.ca/download files/Piontek_Mary_203.B.doc
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■ Beliefs, Events, and Values Inventory (BEVI) – The BEVI is a 494-item instrument
that is designed to evaluate basic openness, receptivity to different cultures,
tendency to stereotype, and self / emotional awareness. The BEVI asks ‘extensive
background and demographic items along with validity and process scales in order to
assess variables that may influence or shape both the processes and outcomes of
international or multicultural learning.’
■ Personal Intercultural Change Orientation (PICO) – Based on the Deep Culture
model of intercultural learning by Shaules, The Personal Intercultural Change
Orientation (PICO) instrument was developed. It measures two orientations related
to the psychological stresses associated with dealing with new cultural environments:
1) an individual ‘s orientation towards change vs. stability, and
2) whether an individual references decisions internally based on existing knowledge
and values or externally, based on the knowledge and values of others. These two
measurements are combined to produce four dimensions that represent different
intercultural learning orientations: proactive, protective, attentive, and adaptive.
http://www.pico-global.com/Default.aspx?l=2
■ Cultural Competence Self Assessment Protocol for Health Care Organisations and
Systems – Developed by Dennis Andrulis, Thomas Delbanco, Laura Avakian and Yoku
Shaw-Taylor, this tool can be used by health services, including hospitals and clinics,
to conduct organisational assessments of their cultural competence. The protocol’s
questions are organized according to the following four cornerstones of cultural
competence:1) health care organisation's relationship with its community; 2) the
administration and management's relationship with staff; 3) inter-staff relationships
at all levels; and 4) the patient/enrollee-provider encounter.
http://erc.msh.org/provider/andrulis.pdf
■ Measures of Cultural Competence - The American Institutes of Research prepared a
report for the Office of Minority Heath US Department of Health and Human
Resources entitled, Cultural competence and Nursing: A Review of Current Concepts,
Policies and Practices. I n Appendix C-1 there is a chart entitled Measures of Cultural
Competence (page 83 ) that lists cultural assessment tools for healthcare
professionals.
http://thinkculturalhealth.org/ccnm/documents/CCNMEnvironmentalScanFINAL2004.
pdf
■ Tools for Assessing Cultural Competence - Program For Multicultural Health has a
website that contains a web page entitled, Tools for Assessing Cultural Competence.
This webpage can be accessed at:
http://www.med.umich.edu/multicultural/ccp/Assessments.doc. This website also
has a section devoted to other tools that assess institutional and organisational
cultural competence. This webpage can be accessed at:
http://www.med.umich.edu/multicultural/ccp/iia.htm#HPA
■ Resources in Cultural Competence Education For Health Care Professionals – In this
California Endowment publication (pages 38-46), Dr. Gilbert (2003) provides a list of
organisational and healthcare professional cultural assessment tools. This report can
be accessed at:
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http://www.calendow.org/reference/publications/pdf/cultural/TCE02182003_Resources_in_C.pdf
■ Summary Report Cultural Competence in Primary Health Care: Perspectives, Tools
and Resources – Janet Rhymes and Darren Brown published a report entitled,
Summary Report Cultural Competence in Primary Health Care: Perspectives, Tools
and Resources. This report provides a brief overview of the concept of cultural
competence with an emphasis on useful tools and resources. This report can be
accessed at:
http://www.cdha.nshealth.ca/programsandservices/diversityandinclusion/culturalCo
mpetence.pdf
■ Tool for Assessing Cultural Competence Training (TACCT) – Developed by the
Association of American Medical Colleges (AAMC ) to help medical schools assess
cultural competence training, the Tool for Assessing Cultural Competence Training
(TACCT) is a self-administered assessment tool with broad applicability to other
health professions disciplines. It is designed to examine all components of a
curriculum, including the following areas: where culturally competent care is
currently taught, educational elements that have been previously unrecognised,
where gaps in the curriculum exist, and planned and unplanned redundancies. It
includes specific domains and components and can be viewed at:
http://www.aamc.org/meded/tacct/culturalcomped.pdf;
http://www.aamc.org/meded/tacct/tacct.xls.
The article, ‘Cultural Competence Education for Medical Students: Assessing and
Revising Curriculum,’ describes the tool and its use. This article can be accessed at
http://www.aamc.org/meded/tacct/culturalcomped.pdf. For more information about
the tool contact Dr. Ella Cleveland at ecleveland@aamc.org or (202) 828-0531.
■ Patient Report Measure of Provider Cultural competence – Authors Lucas,
Michalopoulou, Falzarano, Menon and Cunningham developed a theoretically
grounded and patient report measure of provider cultural competence. This tool is
based on a study of predominantly African American patients (N = 310) who were
recruited from three urban medical clinics to complete a survey about their
relationship with their physician. Psychometric analyses supported a tripartite model
of cultural competence that was comprised of patient judgments of their physician's
cultural knowledge, awareness, and skill. Citation: Lucas, T., Michalopoulou, G.,
Falzarano, P., Menon, S., and Cunningham, W. (2008). Healthcare Provider Cultural
competence: Development and Initial Validation of a Patient Report Measure. Health
Psychology, 27(2), 185-193.
■ Cultural Competence Tools - Hogg Foundation For Mental Health has complied a
resource list entitled Cultural Competence Tools. This resource list includes some
examples of the following types of cultural competence tools:
o Organisational Tools to assess their organisation’s level of cultural competence at
an administrative level.
o Provider Tools to assess clinicians' cultural competence in working with clients.
o Client Tools to assess clients' experience of the organisation and/or clinician’s
cultural competence.
http://www.hogg.utexas.edu/programs_cai_tools.html
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■ Cultural Competence Assessment Tool (CCAT) - Sponsored by Blue Cross Blue
Shield of Massachusetts Foundation, the Cultural Competence Assessment Tool
(CCAT) guides healthcare organisations through an examination of the administrative
structures and practices described in the CLAS standards. Denise Dodd, PhD,
developed this tool with input from staff at the Boston Public Health Commission.
http://www.bphc.org/director/pdfs/disparities_assess-tool.pdf
■ Organisational Cultural Competence Assessment Profile – The Health Resources
and Services Administration (HRSA) sponsored a project to develop indicators of
cultural competence in healthcare delivery organisations. This project is aimed to
contribute to the methodology and state-of-the-art of cultural competence
assessment. The product - An Organisational Cultural Competence Assessment
Profile - builds upon previous work in the field, such as the National Standards for
Culturally and Linguistically Appropriate Services (CLAS), and serves as a future
building block that advances the conceptualization and practical understanding of
how to assess cultural competence at the organisational level. The project was
implemented through a contract with The Lewin Group, Inc. HRSA's Office of Minority
Health and Office of Planning and Evaluation provided both oversight and substantive
input to the project.
http://www.hrsa.gov/culturalcompetence/indicators/default.htm#Assessing
■ Cultural Self-Assessment Resources and Tools for Self-Assessment of Cultural and
Linguistic Competence – The National Center For Cultural Competence in Health Care
(NCCC) has developed the webpage Curricula Enhancement Module Series, that
contains ‘Cultural Self-Assessment Resources’ and ‘Tools for Self-Assessment of
Cultural and Linguistic Competence.’
http://www.nccccurricula.info/resources_mod2.html#appendixa
■ Cultural Sensitivity Personal Reflection Self-Assessment – This tool was developed
to heighten awareness of how one views clients from culturally and linguistically
diverse populations (Goode, T. D.1989, revised 2002).
http://www.asha.org/NR/rdonlyres/E7805A1A-CCD2-4A35-B84AED889318EFA0/0/personal_reflections.pdf
■ Cultural Sensitivity Service Directory Self-Assessment – This tool was developed to
heighten awareness of how one views clients from culturally and linguistically diverse
populations (Goode, T. D.1989, revised 2002).
http://www.asha.org/NR/rdonlyres/07693109-C4F6-48EA-BFC358874C8998F9/0/service_delivery.pdf
■ Cultural competence Challenge – The American Academy of Orthopaedic Surgeons
(AAOS) has developed the Cultural competence Challenge to assist in learning or
reinforcing one’s individual knowledge of cultural care issues, without the pressure of
an actual patient encounter. It is stated to be particularly useful in a residency
setting to teach the next generation of orthopaedists. The CD-ROM program was
showcased at their 2005 AAOS Annual Meeting and is offered via the AAOS Diversity
in Orthopaedics Web site: http://www.aaos.org/diversity. Contact Dr. Ramon at
ramon@jimenez.net.
■ Colour-Blind Racial Attitude Scale (CoBRAS) – The CoBRAS is a 20-item self-report
measure. Participants respond utilizing a 6-point Likert-type scale, the scale ranges
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from 1 (strongly disagree) to 6 (strongly agree). The three subscales which comprise
the CoBRAS are Unawareness of Racial Privilege, Unawareness of Institutional
Discrimination, and Unawareness of Blatant Racial Issues. Total score which
encompasses all three subscales can range from 20 to 120 with higher scores
representing more colour-blind racial attitudes. Citation: Neville, H. A., Lilly, R. L.,
Duran, G., Lee, R. M., and Browne, L. (2000). Construction and initial validation of
the Color-Blind Racial Attitudes Scale (CoBRAS). Journal of Counselling Psychology,
47, 59-70.
■ Eastern State University's Office of Cultural Affair – Eastern State University's
Office of Cultural Affair has a comprehensive website on cultural resources that
contains a section on ‘Evaluation.’ This section provides information on over 10
cultural assessment tools. http://www.etsu.edu/oca/Resources.asp.
■ Clinical Cultural competence Questionnaire (CCCQ) – The Center for Healthy
Families and Cultural Diversity, Department of Family Medicine, UMDNJ-Robert Wood
Johnson Medical School has developed the Clinical Cultural competence
Questionnaire (CCCQ) for assessing physicians' knowledge, skills, and attitudes
relating to the provision of culturally competent health care to diverse patient
populations. http://www2.umdnj.edu/fmedweb/chfcd/aetna_foundation.htm.
■ Organisational Cultural Competence: Self-Assessment Tools For Community Health
and Social Service Organisations – The Centre for Research on Community Services
of Centretown Community Health Center at the University of Ottawa produced a
report entitled, Organisational Cultural Competence: Self-Assessment Tools For
Community Health and Social Service Organisations. The purpose of this report was
to identify and review the most relevant assessment tools for the set of
organisational cultural competence standards and to make recommendations
regarding the future evaluation of organisational cultural competence
http://www.socialsciences.uottawa.ca/crcs/pdf/organisational_cultural_competence_
21-12-2005.pdf
■ Clinical Cultural competence Training Questionnaire (CCCTQ) – Developed by
Krajic, Like, Schulze, Strabmayer, Trummer, and Pelikan, the Clinical Cultural
competence Training Questionnaire (CCCTQ) is an adapted version of the CCCQ for a
hospital setting. This European Union Migrant Friendly Hospitals initiative tool is
translated into seven languages.
http://www.mfh-eu.net/public/experiences_results_tools/cct_eval_instruments.htm
■ The Client Cultural competence Inventory (CCCI) – The CCCI was developed
through a process that incorporated information from focus groups with providers
and families, interviews, and a review of relevant research literature. The CCCI is
administered via a structured interview. In the field test family members were asked
to rate service coordinators by responding to items grouped into four subscales:
respect for cultural differences, community and family involvement, appropriateness
of assessment and treatment options, and agency services and structure. Results
gave evidence of the tool’s usefulness both in assessing cultural competence directly
and in providing valuable informational input into a larger process of planning for
continuous quality improvement. The research team continues gathering data and
refining the CCCI. They are seeking collaborations with communities or organisations
that are interested in using the instrument and that are willing to share data so
psychometric properties of the scale can be further investigated. For more
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information, contact Sara Hudson Scholle, Ph.D., Assistant Professor of Psychiatry at
the University of Pittsburgh at (412) 624-1703 or scholles@pitt.edu.
■ SIETAR-Europa – The website, SIETAR-Europa, lists an annotated bibliography of
over 50 intercultural assessments and instruments. These tools can be found at
http://www.sietar.de/SIETARproject/Assessmentsandinstruments.html
■ Assessment Tools of Intercultural Communicative Competence – Fantini (2006)
developed a list of 87 Assessment Tools of Intercultural Communicative Competence.
http://www.experiment.org/gsi/Appendix%20F.%20ICC%20Assessment%20Tools_8
7-94_.pdf.
■ Cross-Cultural Diversity Experiences and Attitudes Questionnaire – Developed by
Guiton et al. 2007, is a 55-item questionnaire measuring medical
students' background, experiences, and attitudes related to cross-cultural diversity.
■ The Slope Index of Inequality (SII) – A spreadsheet tool designed to help the user
calculate socioeconomic inequalities in health within an area using small area health
measures. Based on Low. A. and Low, A. (2004). Measuring the Gap: Quantifying
and Comparing Local Health Inequalities. Journal of Public Health Medicine,
26(4):388-396.
■ Communication, Curriculum and Culture (C3) Instrument – Developed by Haidet,
Adam, and Chou, the purpose of this instrument is to help educators characterize
and understand the hidden curriculum at their own institutions. The authors
developed survey items to measure three content areas of the hidden curriculum
with respect to patient-centered care. These content areas include role modelling,
students' patient-care experiences, and perceived support for students' own patientcentered behaviors. The survey was distributed to third- and fourth-year students at
ten medical schools in the United States. Using factor analysis, the authors selected
items for the final version of the C3 Instrument. Citation: Haidet, P., Adam, K. and
Chou, C. (2005). Characterizing the Patient-Centeredness of Hidden Curricula in
Medical Schools: Development and Validation of a New Measure. Academic Medicine,
80(1), 44-50.
■ Self-Administered Instruments to Measure Cultural Competence of Health
Professionals: A Systematic Review - Gozu (2007) and colleagues systematically
reviewed articles published from 1980 through June 2003 that evaluated the
effectiveness of cultural competence curricula targeted at health professionals by
using at least one self-administered tool. They included 45 articles in their review
comprising a total of 45 unique instruments (32 learner self-assessments, 13 written
exams) that were used in the 45 articles. They concluded that most studies of
cultural competence training used self-administered tools that have not been
validated. Citation: Gozu, A., Bass, E., Powe, N., Cooper, L., Beach, M., Price, E.,
Gary, T., Robinson, K., Palacio, A., Smarth, C., Jenckes, M. and Feuerstein, C.
(2007). Self-Administered Instruments to Measure Cultural Competence of Health
Professionals: A Systematic Review. Teaching and Learning in Medicine, 19(2), 180190.
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■ Review of Multidisciplinary Measures of Cultural Competence for Use in Social Work
Education – Krentzman, A. and Townsend, A. (2008) sought measures of cultural
competence from as many sources as possible and found a total of 19
measures/instruments that met the inclusion criteria for this analysis. The tools were
developed between 1986 and 2005. They come from various disciplines including
social work, counselling psychology, college student affairs, pharmacy, nursing,
medicine, applied health, allied health sciences, and education. All were written in
the United States except for one developed in the United Kingdom.
This article provides an excellent review of these tools. Citation: Krentzman, A. and
Townsend, A. (2008). Review of Multidisciplinary Measures of Cultural Competence
for Use in Social Work Education. Journal of Social Work Education at:
http://www.accessmylibrary.com/coms2/summary_0286-34684777_ITM
Mental Health Assessment Tools
■ Making Children’s Mental Health Successful: Organisational Cultural Competence: A
Review of Assessment Protocols –This monograph presents the findings from a
review of cultural competence assessment tools designed for the use at the
organisational level that focused on health or mental health. The search for
assessment tools meeting criteria yielded 45 instruments. A final selection of 17
organisational assessment instruments was examined in this report. Citation:
Harper, M., Hernandez, M., Nesman, T., Mowery, D., Worthington, J., and Isaacs, M.
(2006). Organisational cultural competence: A review of assessment protocols, FMHI
pub. no. 240-2). Tampa, FL: University of South Florida, Louis de la Parte Florida
Mental Health Institute, Research and Training Center for Children’s Mental Health.
http://www.iffcmh.org/Assessment%20Protocols.pdf
■ Cultural Competence Self-Assessment Questionnaire (CCSAQ) – Developed by
James Mason (1995), the CCSAQ is designed to assist service agencies working with
children with disabilities and their families in self-evaluation of their cross-cultural
competence. The measure is based on the Child and Adolescent Service System
Program Cultural Competence Model. This model describes cultural competence in
terms of four dimensions: attitude, practice, policy, and structure. This instrument is
intended to help service providers and staff at child and family serving agencies to
assess their cross-cultural strengths and weaknesses in order to design specific
training activities or interventions that promote greater competence across cultures.
The Cultural Competence Self-Assessment Questionnaire (CCSAQ) was designed for
use in child and adolescent mental health systems.
■ CAMHS CCATool – The Children and Adolescent Mental Health Services (CAMHS)
Cultural Competence in Action Tool (CCATool) is a tool that measures the cultural
competence of individuals working with children and adolescent mental health
services. It is based on the Papadopoulos, Tilki and Taylor's model of cultural
competence. Citation. Papadopoulos, R., Tilki, M. and Ayling, S. (2008). Cultural
Competence in Action for CAMHS: Development of a Cultural Assessment Tool and
Training. Contemporary Nurse, 28(2), 129-140.
Advances in Contemporary Transcultural Nursing 2nd edition.
■ Organisational Cultural Competence: A Review of Assessment Protocols – Authored
by Harper, M., Mernandez, M., Nesman, T., Mowery, D., Worthington, J., and Isaacs,
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M. (2006), is a publication that contributes to understanding how cultural
competence is currently operationalised and measured at the organisational level.
This monograph compares organisational assessment instruments through the
following questions: For what type of organisation was the instrument developed?
How were the instruments developed? How do the authors define cultural
competence? What domains do the authors use as categories of analysis?
http://rtckids.fmhi.usf.edu/rtcpubs/CulturalCompetence/protocol/CultCompProtocol.p
df
■ Build the Field and They Will Come: Multicultural Organisational Development for
Mental Health Agencies - Authored by Zetzer and Shockley (2005), this 123-page
document is a Multicultural Access and Treatment Demonstration Project at Antioch
University funded by the California Endowment. It contains an excellent compilation
of strategies to enhance cultural competence in mental health agencies. Pages 8-14
of this document provides readers with an annotated bibliography of several
organisational cultural assessment tools. In addition, pages 31-33 consists of an
annotated bibliography of several individual cultural assessment tools.
http://www.calendow.org/reference/publications/pdf/mental/MHAntioch.pdf
■ Consolidated Culturalogical Assessment Tool (C-CAT) Tool Kit – The Ohio
Department of Mental Health, released the C-CAT, which is a set of dynamic
measurement instruments that allow systems and organisations to assess their
cultural competence from the perspective of an array of raters. The C-CAT Tool Kit
includes the C-CAT instruments, a stand-alone database, and training and
promotional materials. The C-CAT Tool Kit was developed in conjunction with mental
health consumers, family members, service planners and providers, and the
Outcomes Management Group, a Columbus-based management consulting firm.
http://www.ccattoolkit.org/
■ A Practical Guide for the Assessment of Cultural Competence in Children’s Mental
Health Organisations – With support from a federal grant from Child Mental Health
Services of the Department of Health and Human Services, the Technical Assistance
Center of Judge Baker Children’s Center developed a manual with a list of cultural
assessment tools. This manual, A Practical Guide for the Assessment of Cultural
Competence in Children’s Mental Health Organisations, authored by Dr. Monica
Roizner, is a guide to planning and implementing cultural competence assessments,
with brief reviews of 14 assessment tools, resources for post-assessment cultural
competence, and contact information. It is useful to agency and program
administrators, providers, and human resource personnel, cultural competence
trainers, and family members.
http://www.jbcc.harvard.edu/publications.htm
■ The California Brief Multicultural competence Scale (CBMCS) – The CBMCS can be
used by an agency to identify the training needs of the agency staff. It has its own
training program that ‘flows’ from the scale. The CBMCS is a likert scale consisting of
21 items representing 4 factors: Multicultural Knowledge: Issues of acculturation,
racial/ethnic identity, language, etc.; Awareness of Cultural Barriers: Challenges
people of color experience accessing mental health services; Sensitivity to
Consumers: What does it mean to be a person of color AND a mental health
consumer of services; and Sociocultural Diversities: formerly (Nonethnic Ability)
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Issues of gender, sexuality, aging, social class, and disability. Cronbach’s Alpha of
internal consistency ranges from .90 to .75. Citation: Gamst, G., Dana, R., DerKarabetian, A., Aragon, M., Arellano, L., Morrow, G. and Martenson, L. (2004).
Cultural competence Revised: The California Brief Multicultural competence Scale.
Measurement and Evaluation in Counseling and Development, 37(3),163-187.
http://www.cbmcs.org
■ Compendium of Culturally-Sensitive Assessment Tools and Inventories – The West
Australian Transcultural Mental Health Centre took part in a project that developed
the Compendium of Culturally-Sensitive Assessment Tools and Inventories. This
project aims to assist clinicians in assessing the mental health of people from
culturally and linguistically diverse backgrounds.
Contact: Valza.Thomas@health.wa.gov.au
■ Consumer Based Cultural competence Inventory – Cornelius and colleagues
developed a 52-item consumer assessment instrument of the cultural competence of
mental health providers. Following a 2-year, community-driven instrument
development process, this consumer assessment tool was administered to 238
African American, Latino, and Vietnamese American mental health consumers across
the state of Maryland. The overall instrument had a Cronbach’s alpha of .92.
Research on the tool is published in the following citation: Cornelius, L., Booker,
N., Arthur, T., Reeves, I. and Morgan, O. (2004). The validity and reliability testing
of a consumer-based cultural competence inventory. Research on Social Work
Practice, 14(3):201-9.
■ Developing Cultural Competence in Disaster Mental Health Programs: Guiding
Principles and Recommendations - This document is written by Drs. Athey and
Moody-Williams. This guide includes two sections and six appendices. Section One
explores the nature of culture and disaster and discusses cultural competence in the
context of disaster mental health services. Section One also presents the Cultural
Competence Continuum and a list of questions to address in a disaster mental health
plan. Section Two sets forth nine guiding principles for culturally competent disaster
mental health services and related recommendations for developing these services.
The appendices provide an annotated bibliography of cultural competence resources
and tools as well as a Cultural Competence Checklist for Disaster Crisis Counselling
Programs. http://www.mentalhealth.samhsa.gov/publications/allpubs/SMA033828/default.asp
■ State Mental Health Agency Cultural Competence Activities Assessment – This
assessment was developed by the National Association of State Mental Health
Program Directors and the National Technical Assistance Center for State Mental
Health Planning based on discussion at two expert meetings. The assessment
consists of questions appropriate for state mental health agencies in ten areas of
cultural competence. The categories include the Commissioner's Personal Leadership,
Staff and Stakeholder Commitment, Responsibility for Cultural Competence, Cultural
Competence Advisory Committee, Organisational Self-Assessment, Data Analysis,
Cultural Competence Plan, Linguistic Competence, Standards and Contractual
Requirements, and Resources.
http://www.nasmhpd.org/general_files/publications/cult comp.pdf
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■ Cross-cultural Counselling Inventory – Revised (CCCI-R) - CCCI-R was originally
created as an 18-item scale used by learners to rate the behaviour of a counsellor in
a short video of a counselling session. The developers of the instrument suggest that
it is best used for providing feedback during training – by faculty, peers, and clients
– during simulated or actual counselling sessions, and as a self-assessment tool. This
instrument has been cited in more than 75 scientific articles. Citation: LaFromboise,
T. D., Coleman, H. L. K., and Hernandez, A. (1991). Development and factor
structure of the Cross-cultural Counseling Inventory – Revised. Professional
Psychology: Research and Practice, 22(5): 380-88.
■ Multicultural Counselling Awareness Scale (MCAS) – The MCAS, a revision of the
MCAS: B, is a 32-item self-report measure that assesses respondents' knowledge
and awareness of multicultural competence. The instrument was developed for use
by counsellors and has been tested on both professional and trainee populations.
Citation: Ponterotto, J. G., Gretchen D., Utsey, S. O., Rieger, B. P., and Austin, R.
(2002). Revision of the Multicultural Counselling Awareness Scale.
Journal of Multicultural Counselling and Development, 30: 153-80.
■ Multicultural Awareness-Knowledge-and Skills Survey – Counsellor Edition- Revised
(MAKSS-CE-R) – The MAKSS-CE-R is a self-assessment instrument that is based on
the MAKSS instrument, developed in 1990 which consisted of 60 self-report items on
three subscales of knowledge, skills and awareness. The MAKSS-CE-R was revised in
2003 to assess the impact of training on learners' multicultural counselling
competence. The MAKSS-CE-R now consists 33 items (10 items each for the
Awareness and Skills subscales and 13 items for the Knowledge subscale) Citation:
Kim, B. S. K., Cartwright, B. Y., Asay, P. A., and D’Andrea, M. J. (2003). A revision
of the Multicultural Awareness, Knowledge, and Skills Survey-Counsellor Edition.
Measurement and Evaluation in Counselling and Development, 36: 161-80.
■ Multicultural Counselling Competence and Training Survey (MCCTS) – Developed
by authors Holcomb-McCoy and Myers in 1999, the MCCTS is a self-report
instrument containing 32 behaviourally stated items and 29 items that require
participants to provide information regarding their entry-level counselling training
experiences and demographics such as gender, age, race, and year of graduation.
These authors assert that there were five factors underlying the multicultural
counselling competence items of the MCCTS: Multicultural Knowledge, Multicultural
Awareness, Multicultural Terminology, Knowledge of Racial Identity Development
Theories, and Multicultural Skills. In the calculation of internal consistency reliability
coefficients (Cronbach's alpha) for the instrument, alphas of .92, .92, .79, .66, and
.91 were derived for the Multicultural Knowledge, Multicultural Awareness,
Multicultural Terminology, Racial Identity, and Multicultural Skills subscales,
respectively (the somewhat lower reliability coefficient for the Racial Identity
subscale.
■ MHA/MHP/CCAG – The Mental Hygiene Administration/Maryland Health Partners
(MHA/MHP) Cultural competence Advisory Group (CCAG) developed a 52-item scale
(still in progress) to assess clients' perceptions of the Public Mental Health System.
Statistical analysis identified four core domains assessed by the instrument: as 1)
the ability to tune into psycho-social, medical, and spiritual needs; 2) the
accessibility of services and the willingness to negotiate on priorities for care; 3)
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efforts to reach out to racially diverse communities; and 4) the willingness to listen
to and respect people in recovery from various cultures. Citation: T. E., Reeves, I.,
Morgan, et al. (2005). Developing a Cultural Competence Assessment Tool for People
in Recovery From Racial, Ethnic and Cultural Backgrounds: The Journey, Challenges,
and Lessons Learned. Psychiatric Rehabilitation Journal, 28(3):pp.243-50.
■ The Cultural competence Standards and Audit Tool (the Tool) – the Tool was
developed and produced by the Multicultural Forum for Mental Health Practitioners.
This Western Australia based group of mental health clinicians was a policy and
advisory group to the state’s mental health directorate on issues concerning service
development and provisions for Western Australia’s Culturally and Linguistically
Diverse (CALD) mental health consumers. The central objective of the Tool is to
ensure that the organisational culture and practice of mental health services
effectively accommodates Western Australia’s growing multicultural population. The
Performance Measures in the Tool were designed to have three functions: to
measure the extent to which services can achieve the Cultural competence
Standards; to guide services in how to strive for best practice and quality-assured
service provisions to CALD communities; and to assist services in implementing
cultural competence initiatives at all levels. Copies of the Cultural competence
Standards and Self-Assessment Audit Tool may be obtained from the Mental Health
Division, Department of Health, Western Australia - 08 9222 4222. To learn more
about this tool, please visit:
http://www.mmha.org.au/mmha-products/synergy/edition-1-2007/using-201cthetool201d-to-test-yourself
■ Multicultural Counselling Inventory (MCI) – The MCI consists of 43 self-report
items that assesses multicultural competencies on a 4-point Likert scale (1 = very
inaccurate; 4 = very accurate) asking the respondent to indicate the degree to which
the scale items describe their work as counselors/trainers. The MCI is based on a
conceptual framework from Sue et al. (1982) on multicultural counseling
competencies on the following four subscales: Awareness (ten items measure
multicultural sensitivity, interactions, and advocacy in general life experiences and
professional activities); Knowledge (eleven items measure treatment planning, case
conceptualization, and multicultural research); Skills (fourteen items measure
general and specific multicultural skills); and Relationship (eight items measure the
interaction process with the minority patient for example, comfort level, world view,
and trustworthiness). Citation: Sodowsky, G., Taffe, C., Gutkin, T. and Wise, S.
(1994). Development of the Multicultural Counselling Inventory (MCI): A self-report
measure of multicultural competencies. Journal of Counselling Psychology, 41,pp.
137-148.
■ Measures of Cultural Competence: Examining Hidden Assumption – This article,
authored by Kumas-Tan et. al (2007), critically examines the quantitative measures
of cultural competence most commonly used in medicine and in the health
professions and identifies underlying assumptions about what constitutes competent
practice across social and cultural diversity. Citation: Kumas-Tan, Z., Beagan, B.,
Loppie, C., MacLeod, A. and Frank, B. (2007). Measures of Cultural Competence:
Examining Hidden Assumptions. Academic Medicine. 82(6), 548-557.
http://www.healthsystem.virginia.edu/internet/surgery-clerkship/Measures-ofCultural-Competency-June-2007.pdf
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