Published by the Statewide Quality Branch

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

MelbourneVictoria

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:

Acknowledgements

This report was written by the Institute for Community, Ethnicity and Policy Alternatives, VictoriaUniversity

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.

CONTENTS

EXECUTIVE SUMMARY......

1. INTRODUCTION......

2. LITERATURE REVIEW METHODS......

3. DEFINING CULTURE, CULTURAL COMPETENCE AND CULTURAL DIVERSITY

4. RELEVANCE OF CULTURAL COMPETENCE TO HEALTH AND WELLBEING

5. MODELS OF CULTURAL COMPETENCE......

5.1 Discussion and Analysis: How do the models guide intervention?......

6. CULTURE AS A FACTOR IN SAFETY AND RISK MANAGEMENT IN HEALTH SYSTEMS

7. GOVERNMENT POLICY AND REPORTING FRAMEWORKS FOR CULTURAL DIVERSITY

7.1. Mapping Cultural Diversity Policy, Planning and Reporting Arrangements for Cultural Diversity

Health Service Cultural Diversity Plan (HSCDP)......

7.2 Discussion......

7.3 Selected Commonwealth and State Policies and Reporting Frameworks

8. STANDARDS OF CULTURAL COMPETENCE FOR HEALTH SERVICES

8.1 Australian Standards......

8.2 International standards......

8.3 Discussion

9. INDICATORS AND ASSESSMENT TOOLS......

10. TOWARDS A FRAMEWORK OF CULTURAL COMPETENCE ASSESSMENT

11. CONCLUSION......

REFERENCES......

RESOURCES......

Appendix 1......

Minimum Reporting Requirements Under HSCDP......

Appendix 2......

Core Strategies of the Cultural diversity plan for Victoria’s specialist mental health services 2006–2010

Appendix 3......

Culturally and Linguistically Appropriate Services and Standards (USA)....

Appendix 4......

Lewin Group Cultural Competence Domains (2002)......

Appendix 5......

Cultural Competence Assessment Tools......

Mental Health Assessment Tools......

EXECUTIVE SUMMARY

This literature review was prepared by the Institute for Community, Ethnicity and Policy Alternative (ICEPA), VictoriaUniversity. The review wascommissioned 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 competencefound 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.

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 beembedded 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 indicatesthere 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.

1. INTRODUCTION

The Department of Human Services (the department) has commissioned VictoriaUniversity’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.

1. 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.

1. 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.

1. 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.

1. 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 reportincorporates 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 reviewhas 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 toinform decisions about the scope, content, and mechanisms to enhance any existing frameworks for culturally competent health care services.

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).

3. DEFINING CULTURE, CULTURAL COMPETENCE AND CULTURAL DIVERSITY

Various definitions of culture, diversity, cultural diversity and cultural competence were generated fromrelevant literature.However before defining cultural diversity and cultural competence, it is vital to understand the concept of culture. Cultureis a much written about concept; as early 1871Edward 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).

Diversityas 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 diversityis also another broadconcept;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 non-mainstream 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, 2006pp.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 withinthe 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 cultural competence (Betancourt et al 2002, Brach and Fraser 2000). Definitions have focused on the individual or clinician level, and the organisational level. Somedefinitions 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 singledefining there is some agreement that building cultural competence capacity will improve health care delivery to diverse populations.

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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 Victoria23.8 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 factorsare 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 factorsreduce 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 appropriate services thereis potential to reduce disparities and improve outcomes,increase efficiency of clinical and support staff andimprove 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 overcomeby addressing cultural differences, and result in improved access and quality of care for culturally diverse populations.