SAMHSA's National Mental Health Information Center

This Web site is a component of the SAMHSA Health Information Network

About the Program

Evidence-Based Practices

Community Support

Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Appendix C : Practical Measures of Cultural Competence in Managed Care

Jeff King, Ph.D.
Native American Counseling, Inc.
Denver, Colorado

December 1998

The development of an instrument to assess cultural competency among mental health agencies is a formidable task. There are numerous dimensions to cultural competency as well as mental health provision in a managed care setting. My approach will be to identify what I think are the key areas to consider, to offer what others have contributed in this area, and to ask pertinent questions about this type of evaluation. These, in turn, will help formulate more specifically the design of the measure or measures.

Initial Approach

Obviously, the first question is "What approach are we going to take in our evaluation?". Are we evaluating all the components within an agency from executive board to clerical staff? Or, are we to highlight the aspects of the agency more directly related to mental health provision? Are we evaluating consumer/community satisfaction or competency within the agency or both? Hopefully, these are related. Furthermore, are we evaluating cross-sectionally, longitudinally, or what?

Are we evaluating a program as "in development toward competence" or are we summarizing a program's effectiveness over a specified period of time? What perspective are we taking? Orlandi (1992) suggests there are three basic perspectives: (a) Process Level evaluation looks at the ongoing operating procedures (more of a quality assurance review) and requires a formative perspective; (b) Program Level, which addresses how a program achieves its specific goals and uses both formative and summative perspectives; (c) Evaluation Research Level which uses rigorous experimental designs and statistical analyses to examine the internal and external validity of programmatic effectiveness.

Purpose of Measure

Hopefully, the measure will be used to increase the quality and sensitivity of services and that these services will improve over time. This measure can also provide the opportunity to discover both positive and negative effects associated with service provision strategies. Finally, this measure may be able to allow staff, clinicians, and administrators to provide specific, pragmatic, comprehensive, and effective descriptions of their cultural competencies. These in turn can be used by other agencies making these same attempts (Casas, 1992).

Specificity of Measure

If this measure is going to be used across cultures, it must be generic enough to access common dimensions across ethnicities. Perhaps the measure can have a generic component for cross-comparisons of the programs for various ethnic groups and a certain portion allotted to culture-specific items that can provide much needed emic information for local evaluation and programmatic purposes.

Cultural Competency Levels

Cross, Bazron, Dennis, and Isaacs (1989) suggest a cultural competency continuum on which agency effectiveness may be evaluated, ranging from cultural destructiveness on one end to cultural proficiency on the other. A detailed quote of these "stages" is provided as it gives specific definitions for levels of competency.

Cultural Competency Levels Chart

These continuum processes are further defined in Cross, et al, (1982) can provide a framework for developers in determining item content.

Domains of Cultural Competence for an Agency

Needs Assessment

An agency must know the community it reports to serve in terms of needs. The following questions are taken (with modifications) from Kim, McLeod, and Shantzis (1992) and relate to this type of assessment:
Has the agency conducted a formal needs assessment within the community within the last two years? Were community members consulted/employed in the development of this assessment? Where was the instrument administered? What was the community's response to this survey?

Are data collected and kept for racial/ethnic populations? Are these data shared with consumers, community members, and other community agencies? Are these data used in annual reports, self-evaluation, and planning? Are they submitted to the review of community members, cultural consultants, or consumers?

Training

Has the agency required training for its staff in cultural competency within the last 2 years? Who were the trainers? Were they from the local community? Were these trainings subjected to evaluation by community members, consumers, or cultural consultants? Are there data to reflect the impact of training? Have board members been trained in cultural competency in the last 2 years? Who were the trainers? Were they from the local community? Were these trainings subjected to evaluation by community members, consumers, or cultural consultants? Are there data to reflect the impact of the training?

Staffing Hiring Procedures

What percentage of the targeted ethnic minority group is employed in this agency? In what capacity and at what level? What percent of the staff is bilingual? What percent of the staff is trained in cultural awareness? What percent of the targeted ethnic minority group is represented in an ethnic racial advisory council? What percent of the board members is from the targeted ethnic minority group? What percent of the targeted ethnic minority group is represented at the administrative (or decision-making) level of the agency?

Prior Performance Patterns

Are there linkage with other ethnic minority community groups? Are contract awards given to ethnic/racial service providers for issues specifically related to them? Does the agency set aside funds on behalf of the ethnic minority consumers or communities? Does the mission statement of the organization provide for culturally competent services?

Does the agency adjust holidays to accommodate cultural differences? Does the agency contract with local healers from the community? Does the agency allow consumers/community members to evaluate their performance? Is the agency located in or around the vicinity of the targeted group? Do service hours reflect client accessibility? Does the agency provide educational and other materials in the language or style that can be understood by ethnic minority consumers/community members? Does the agency actively seek to improve relations with the targeted ethnic minority community?

Agency Effectiveness Defined

Kim, McLeod, and Shantzis (1992) provide a formula which gives an overall performance rating for agency effectiveness called the Minority Service Success Rate:

EX = NT x TY/N MSS = AX/EX x 100
EX = Expected number of ethnic minority group clients who could have been served during a selected time period.	NT = Total size of targeted community relative to the larger community.
TY = Total number of clients served by a reference agency during this selected time period.	N = Total population size of a larger community in which targeted community resides.
MSS = Index score of minority service rate.	AX = Actual number of target group clients served by targeted agency during selected time period.

This formula or one like it can help determine item selection and rating schedule for a competence measure.

Provider Competence

There are many scales available that rate provider competency. In fact, The Education and Training Committee of the American Psychological Association's Division of Counseling Psychology (Division 17), conceptualized three dimensions of cross cultural counseling competencies: (a) beliefs-attitudes, (b) knowledges, and ( c ) skills. Included in these were 11 specific minimal skills (Sue, Bernier, Durran, Feinberg, Pedersen, Smith, & Vasquez-Nuttal, 1982). Later, the Professional Standards Committee of the Association for Multicultural Counseling and Development introduced three additional characteristics: (a) counselor's own awareness of their assumptions, beliefs, and biases, (b) an understanding of the world view of the culturally different client, and (c) the development of appropriate intervention strategies and techniques (Sue, Arredondo, & McDavis, 1992). These areas for cultural competence are echoed by many other clinicians and researchers (Cayleff, 1986; Helms, 1990; Lynch & Hanson, 1992; & Smith, 1985).

Some measures hold promise in terms of their statistical validity, however, I think a formal review of these instruments by the panel would be necessary, if indeed, it is decided to assess cultural competence at this level.

References

Casas, J. M. (1992). A Culturally Sensitive Model for Evaluating Alcohol and Other Drug Abuse Prevention Programs: A Hispanic Perspective. In, Orlandi, M. A. (Ed.) Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working With Ethnic/Racial Communities. Office for Substance Abuse Prevention, OSAP Cultural Competence Series 1, U.S. Dept of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, pp. 75-116.

Cayleff, S. E. (1986). Ethical issues in counseling gender, race, and culturally distinct groups. Journal of Counseling and Development, 64, 345-347.

Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Toward a Culturally Competent System of Care. Washington D.C.: Georgetown University Child Development Center.

Helms, J. (1990; ). Toward a model of White racial identity development. In J. E. Helms (Ed.) Black and white racial identity: Theory, Research and Practice. New York: Greenwood Press.

Kim, S., McLeod, J. H., & Shantzis, C. (1992). Cultural Competence for Evaluators Working With Asian-American Communities: Some Practical Considerations. In, Orlandi, M. A. (Ed.) Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working With Ethnic/Racial Communities. Office for Substance Abuse Prevention, OSAP Cultural Competence Series 1, U.S. Dept of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, pp. 203-260.

Lynch, E. W., & Hanson, M. J. (1992). Developing Cross-cultural Competence: A Guide for Working With Young Children and Their Families. Baltimore: Paul H. Brookes Publishing Co.

Orlandi, M. A. (1992). Defining Cultural Competence: An Organizing Framework. In, Orlandi, M. A. (Ed.) Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working With Ethnic/Racial Communities. Office for Substance Abuse Prevention, OSAP Cultural Competence Series 1, U.S. Dept of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, pp. 1-22.

Smith, E. M. J. (1985). Ethnic minorities: Life, stress, social support, and mental health issues. The Counseling Psychologist, 13, 537-579.

Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural competencies and standards: A call to the professional. Journal of Counseling and Development, 70, 477-486.

Sue, D. W., Bernier, J. E., Durran, A., Feinberg, L., Pedersen, P., Smith, E. J., & Vasquez-Nuttal, E. (1982). Professional Forum Position Paper: Cross-Cultural Counseling Competencies, The Counseling Psychologist, 10, 2, 45-52.

Table of Contents | Previous | Next