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Notes from a Roundtable on Conceptualizing and Measuring Cultural Competence

Paper and Presentation Summaries

These paper and presentation summaries are given in the order they were dealt with during the roundtable meeting. Appendix C has the texts of all papers organized alphabetically by author.

Practical Measures of Cultural Competence In Managed Care

Jeff King, Ph.D., Director, Native American Counseling, Inc., Denver, Colorado, and co-chair of the National Native American Managed Care Panel, one of the four cultural competence panels that developed the Core Cultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Groups.

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 to mental health provisions in a managed care setting. King identifies key issues and questions to consider in developing a measure of cultural competence in managed care examining the following areas:

The approach to be taken in the evaluation.
The specific purpose of the measure.
Levels of analysis.
Levels of cultural competence.
Systemic questions.
Rating agency effectiveness.
Provider competencies.

Practical Measures for Population-Based Planning: A Prerequisite in Developing Culturally Competent Services

Josie Torralba Romero, LCSW, consultant on cultural competence and a member of the National Latino Behavioral Health Workgroup, one of four cultural competence panels that developed the Core Cultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Groups.

Two elements of cultural competence - population-based planning and organizational self-assessment - should be considered as prerequisites if one is to measure the cultural competence of individuals and organizations. Romero provides an overview of these two elements, which she sees as essential in establishing a baseline knowledge to begin measuring developmental growth in individuals and organizations. These two planning elements also provide the "context" from which all planning and training must be derived. The two elements mentioned in this paper, population-based planning and organizational self-assessment, are not new to the literature of cultural competence. However, Romero describes them as they relate to the findings of the populations in a particular community, region, or county.

Measuring Cultural Competency: Issues and Dilemmas

Stanley Sue, Ph.D., Professor of psychology and psychiatry, Director of the Asian American Studies Program at the University of California at Davis, and co-chair of the National Asian and Pacific Islander American Panel, one of four cultural competence panels that developed the Core Cultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Groups.

One of the most important tasks in the provision of mental health services is the development of cultural competency and cultural competency measures. Sue proposes three critical characteristics of cultural competence. These are having good general skills, having skills in dynamic sizing, and having culture specific knowledge. Sue maintains that four tasks need to be addressed in establishing measures of cultural competency:

Defining cultural competency (while a number of definitions do exist, the real problem is to arrive at a reasonable consensus on the nature of the term).
Developing measures.
Ensuring adequate psychometric properties and validity.
Considering the usefulness of measures.

The issues within the four tasks have not been satisfactorily addressed in existing measures of cultural competency. Progress on the establishment of measures must be guided by the four tasks.

Issues Pertinent to the Selection of Cultural Competence Measures in Performance Measurement Systems

Mildred Vera, Ph.D., Center for Evaluation and Sociomedical Research, School of Public Health, University of Puerto Rico.

Managed care environments have the responsibility of developing systems of care that address the cultural variations of consumers from diverse ethnic populations. In her paper, Vera examines the product of a joint effort of four national racial/ethnic panels in the formulation of a set of viable performance indicators aimed at improving the ability of managed care organizations to meet cultural competence standards. The role of culture in performance assessment is explored and relevant factors examined for selecting appropriate measures of cultural competence that address systems, and clinical and provider elements.

Cultural Competence Prerequisites for Managed Behavioral Health Care Programs

Joseph M. Torres, Ph.D., consultant, Massachusetts Department of Mental Health, and member of the National Latino Behavioral Health Workgroup, one of four cultural competence panels that developed the Core Cultural Competence Standards in Managed Mental Health Care for Four Underserved/Underrepresented Racial/Ethnic Groups.

The primary purpose for strategic implementation of the national Cultural Competence Standards for Managed Mental Health Care Programs is to promote the systematic development of culturally competent public and private systems of care. Achievement of this goal will require public and managed care organizations to develop strategic cultural competence implementation plans and also program evaluation plans to measure the progress and effectiveness of the cultural competence system of care.

Some basic concepts considered by four national cultural competence workgroups when developing the Cultural Competence Standards for Managed Mental Health Care Programs are discussed in Torres's paper. Torres believes that the Program Evaluation Plan and the Cultural Competence Plan should be concurrently developed and implemented. This would ensure that essential principles and values that generated the Cultural Competence Standards for Managed Mental Health Care Programs would be accurately represented by the evaluation protocols used. In his paper, Torres contends that the gradual development of an effective cultural competence evaluation plan will require the continuous linking and active collaboration between specialists with cultural competence expertise and specialists with program evaluation expertise. The paper considers some of the issues inherent in developing appropriate cultural competence indicators or outcome measures, and the appropriate methodology to assess progress in the implementation of the cultural competence plan and its effectiveness over a specified period of time.

Additional priority issues and barriers to effective mental health care service delivery to Hispanic consumers are discussed from the perspective of the National Latino Behavioral Health Workgroup, including:

Cultural Competence (requires a highly specialized developmental, long-term, multistage process to implement).
Representative participation in workforce.
Quality and design of programs.
Qualified interpreters.
Quality care.
Community improvement and system change.

Linking Values Orientation, Acculturation, and Life Experiences to the Implementation of Services: Recommendations for Four Constructs to be Measured in an Instrument on Cultural Competence of Mental Health Services Delivery

Daniel A. Santisteban, Ph.D., Center for Family Studies, University of Miami, and Frederick L. Newman, Ph.D., Florida International University & Center for Family Studies, University of Miami.

Measurement of cultural competence is a complex but critically important endeavor. Without cultural competence, a system cannot be expected to effectively bring consumers into service or effectively treat consumers of different ethnic and racial backgrounds. In developing an instrument that can be used in evaluating a service systems' cultural competence, there are a number of domains that the measure must cover. The purpose of this paper is to articulate how and why these important domains must be addressed.

First, the instrument must assess the overall competence of the service system in understanding the treatment model and in delivering interventions consistent with the model. That is, cultural competence must be built upon a foundation of basic professional competence and that professional competence cannot be assumed to be present.
Second, the instrument must assess the degree to which a system understands the range of basic values' orientations that consumers from diverse cultures may endorse. This must also include an understanding of how the values and assumptions on which the intervention model is based may be compatible or incompatible with those of the consumers.
Third, the instrument must be capable of assessing the service system's knowledge of the life experiences (immigration and acculturation stress, racial prejudice and discrimination, the sociopolitical standing of the consumer's ethnic group within the host society) that shape the consumers' everyday lives.
Fourth, the instrument must be capable of measuring the systems ability to engage and treat the consumer with ease - that is, the extent to which there is tolerance and comfort with the diverse customs, habits, beliefs, and behaviors that ethnic clients bring with them.

Defining and Measuring Cultural Competence in the Evaluation of Mental Health Services

Lee Sechrest, Ph.D. and Michele Walsh, The Evaluation Group for Analysis of Data, Department of Psychology, University of Arizona.

Race, ethnicity, and culture should not be used interchangeably as they have different meanings. In most instances, in the delivery of mental health services, culture is of focal interest, but occasionally ethnicity, which refers to group identification, is at issue. It may be difficult in many instances to specify what is intended by cultural competence and to distinguish it from general sensitivity to differences among people. This situation arises partly because people are culturally complex and at any given time it may be difficult to determine what the relevant culture is, even if one knows its characteristics. Cultural competence will require broad training in principles of sensitive social interaction as well as in characteristics of local populations being served and the cultural factors likely to be operating among them.

Specific features of local populations and their adaptations need consideration. Language barriers may be of overestimated importance if only because they are usually so obvious. Expectations about patterns of communications and health care beliefs and practices must be known and taken into account, as must sources of stress and coping skills. Family organizational and relational roles are also likely to determine the nature of interactions in service delivery settings.

In general, effective and efficient delivery of mental health services will be fostered if we learn to identify and measure the actual cultural variables in which we are interested rather than simply treating a social address as a proxy for standing on those variables. It is particularly important to identify those variables related to the ways in which services are to be organized and delivered. A wide range of measures is now available, but they need to be both improved and extended.

California's Cultural Competence Plan

Francis Lu, M.D., Professor, Department of Psychiatry, San Francisco General Hospital, University of California.

California's Cultural Competence Plan is an example of a cultural competence requirement that is already in place for county mental health programs across the state. California may be the first state that has regulations in this area. The large number of culturally diverse people in the Medicaid population was the driving force behind the state's effort to get counties to incorporate cultural competence in their managed care plans.

The move to add cultural competence requirements began in June 1995 when California issued its Managed Care Mental Health Plan for Medicaid recipients that had some but not much of a focus on cultural competence. At the request of a number of people, the state moved to add cultural competence to the plan. A Cultural Competence Task Force was created in November 1996 to develop cultural competence plan requirements as an addendum to the Managed Care Plan. The Task Force included California State Department of Mental Health staff, county mental health directors, county cultural competence specialists, academicians, consumers, family representatives, and community-based organizations. In October 1997, the California Cultural Competence Plan requirements were completed using a number of documents to create the requirements, including:

New York State Office of Mental Health Cultural and Linguistic Competence Standards (December 1995 draft).
SAMHSA/CMHS Evaluation Agenda (June 1996).
WICHE/CMHS Latino Cultural Competence Standards (1996) and the Core Cultural Competence Standards (April 1996 prepublication draft).

Each county was required to submit a cultural competence plan to the California Department of Mental Health by July 1998. These plans were reviewed and feedback given to the county.

Definitions and Measurement of Cross-Cultural Counseling Competencies

Frederick T. L. Leong, Ph.D., Department of Psychology, Ohio State University.

Leong's paper begins with some definitions of multicultural counseling versus cross-cultural counseling and cultural competence versus cross-cultural competence. Leong clarifies some concepts in cross-cultural counseling and points out the misapplication of concepts of multicultural counseling and cultural competence. A strong recommendation is made for the use of more specific and accurate terminology of cross-cultural counseling and cross-cultural competence.

Using the conceptual model provided by the Division 17 position paper for cross-cultural counseling competencies, the paper reviews different measures for assessing the awareness, knowledge, and skills dimensions represented by this model. Finally, some caveats about the model and the measures are discussed in detail.

Assessing Cultural Competence in Mental Health Service Delivery

Joseph G. Ponterotto, Ph.D., Counseling Psychology Program, Fordham University, Lincoln Center, New York City.

Mental health delivery systems will be working with an increasingly diverse client base in the coming decades. The majority of providers are not adequately prepared to work across cultural and linguistic differences. Two pressing needs at this time are an adequate definition of cultural competence and the reliable and valid assessment of this competence in both individual and organizational contexts.

This brief position paper addresses these issues and outlines extant competency measures. A recommendation for long-term, combined qualitative and quantitative assessments is presented. Three appendices present sample competency assessments:

The Multicultural Counseling Knowledge and Awareness Scale (MCKAS).
The Multicultural Counseling Competencies Portfolio Assessment.
The Multicultural Counseling Competency Checklist for Academic Counseling Training Programs.

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