Watch a video introduction to this publication by Anne Beal, M.D., M.P.H., senior program officer for the Quality of Care for Underserved Populations Program
You can also watch a Fund E-Forum, with slides and audio from a related presentation delivered at a roundtable event, "Cultural Competency: Understanding the Present and Setting Future Directions," held in New York City on April 7, 2006.
This report reviews the evidence base for the impact of cultural and linguistic competence in health and mental health care on health outcomes and well-being and the costs and benefits to the system. The authors conducted a structured search of Medline from January 1995 to March 2006 to identify primary research articles on health outcomes and well-being. An exploratory search of multiple databases was performed to identify evidence related to the business case. The review of the health outcomes literature indicated that the field is in the early stages of development, with the preponderance of literature defining the concepts and identifying research questions. Some promising studies support the efficacy of cultural and linguistic competence affecting health and mental health outcomes. Evidence of decreased systems costs is not currently present in the literature. The authors identify key gaps in the current literature and specific methodological and funding limitations to be addressed.
Cultural and linguistic competence are widely recognized as fundamental aspects of quality in health care and mental health care—particularly for diverse patient populations—and as essential strategies for reducing disparities by improving access, utilization, and quality of care. However, it is not clear if evidence exists to support the assertion that cultural and linguistic competence improve health outcomes and well-being. Advocates of culturally and linguistically competent care state that the costs of providing such care are offset by potential benefits, but, again, there is limited evidence to support this assertion. This report assesses the current evidence base for the impact and benefits of cultural and linguistic competence in health care and mental health care.
The authors used two approaches to identify the evidence and gaps in research related to health outcomes and well-being, as well as the costs and benefits to the system, or the "business case," for cultural and linguistic competence. They conducted a structured search of Medline from January 1995 to March 2006 to identify primary research articles for review on health outcomes and well-being. They also performed an exploratory search of multiple databases to identify evidence related to the business case, including primary sources, selected reviews, technical reports, and conceptual papers.
A review of the health outcomes literature indicated that the field is in the early stages of development, with a preponderance of the literature exploring and defining the concepts and issues and identifying important research questions. There is now some movement toward pilot and controlled studies to test the impact of cultural and linguistic competence on quality and effectiveness of care. While the Medline search methodology yielded 365 studies that addressed cultural and linguistic competence and health outcomes and well-being, only 25 studies met the criteria for final review. The current evidence provides information about intermediate outcomes of short-term interventions, but none directly address the ultimate outcome of decreased incidence of a disease for a population, or a decrease in morbidity or mortality as a result of the intervention used. Instead, intermediate outcomes such as increased rates of cancer screening or improved HbA1c levels were measured. Most focused on treatment and only two addressed cultural and linguistic competence at the organizational or policy level. Two areas—cancer prevention and early detection and diabetes care and management—predominated the current literature on health outcomes and well-being. None of the studies in these areas defined cultural or linguistic competence, but all met some key criteria (as defined by the National Center for Cultural Competence) in their descriptions of the interventions used.
Current Evidence on Outcomes and Well-Being
The current evidence shows great promise, but better-designed studies are needed to advance the evidence base. Nine studies addressed cancer prevention and early detection. Three used comparison or control groups and found that utilizing patient education approaches—designed with and for the intended audience and consistent with the audience's values, beliefs, and preferred ways of getting information—demonstrated significantly increased behavior changes compared with either no intervention or interventions that were not culturally competent. In addition, eight studies reported findings on interventions and outcomes related to diabetes treatment. Of these, three that had pre- and post-intervention data on the effects of culturally competent interventions reported significantly improved outcomes in terms of physiologic measures associated with better long-term outcomes in diabetes. Only two studies addressed cultural and linguistic competence at the organizational level, with only one reporting on health outcomes. This latter study showed a significant positive relationship between cultural competence policies at sites caring for children with asthma and improved quality care associated with appropriate use of preventive asthma medications and parent satisfaction with care.
While the evidence shows great promise for the impact of culturally and linguistically competent interventions on health outcomes and well-being, significant gaps remain, due largely to methodological issues. Current studies fall short in many areas, including: lack of definition and measurement of cultural and linguistic competence; designs that isolate effects of cultural and linguistic competence; and studies that address ultimate health outcomes of decreased incidence of disease, morbidity and mortality. In addition, few studies examined cultural and linguistic competence at the organizational and policy levels. Future directions for research include: use of validated and shared definitions of cultural and linguistic competence; refined population definitions to include cultural variables other than race, ethnicity or language; use of designs that test the specific effects of cultural and linguistic competence; implementation of longitudinal and large sample studies to investigate ultimate health outcomes; and use of methods and measures that examine the relationship among organizational policies, structures and practices, quality and effectiveness of care, and health outcomes and well-being.
Current Evidence on the Costs and Benefits of Cultural and Linguistic Competence: The Business Case
The authors examined the literature for health and mental health care costs and benefits of cultural and linguistic competence, and the evidence related to specific aspects of the business case for cultural and linguistic competence including market share, cost-benefits, reducing liability, and staff turnover.
Evidence to support the hypothesis proposed—that cultural and linguistic competence would result in decreased system costs—is not currently present in the literature. The research to support the business case for cultural and linguistic competence is still a work in progress. There is a noticeable absence of a broadly defined framework that includes the cost-benefits of cultural and linguistic competence to families, communities, employers, and society. Analysis of costs and benefits of culturally and linguistically competent care is complex and not yet well documented. The literature documents specific costs for services associated with linguistic competence but few studies document the cost of cultural competence.
Most of the literature on cost-benefits center around linguistic competence, specifically the provision of language access services such as interpretation and translation, and to a large extent, the papers are conceptual and inconclusive. The two studies reviewed differ in their findings and reflect the complexity of measuring costs to the system. One study reported increased costs associated with the provision of language access services and justified such costs by describing potential cost-benefits associated with factors like increased access to primary and preventive care and fewer follow-up appointments and complications. The other study reported that the use of trained medical interpreters in the emergency room was cost neutral and that such services reduced emergency department return rates while simultaneously increasing clinic utilization, a less-costly service.
The literature on the cost-benefits of cultural competence almost exclusively focuses on the reduction of racial and ethnic health disparities. However, it does not directly link cultural competence and cost-benefits, nor does it quantify the projected or estimated cost savings of providing culturally competent care by racial or ethnic group, specific diseases or chronic conditions, and types of intervention. Two studies addressed cost-benefits for culturally competent care models. In one, with a very small sample, researchers reported a 50 percent return on investment, with decreased costs due to fewer visits to the emergency room by children with asthma. A second study reported results of a specific diabetes management program, which led to higher first-year costs attributed to increased use of medication and diabetes supplies. At this time, insufficient evidence exists to draw any definitive conclusion on the cost-benefits of cultural competency in health care.
The authors also explored cost-benefits to the system in relation to market share gains or losses. However, no primary sources were found to document this issue and it is ripe for future research. They also reviewed studies related to staff turnover as a system cost, but none examined the relationship between the cultural competence of providers or organizations and retention.
The concept of liability—and specifically, of decreasing the liability of providers or organizations through cultural and linguistic competency—is showing some strong preliminary evidence. The authors cite two documented and costly judgments against health care entities for failure to provide language access services mandated by Title VI of the Civil Rights Act. In addition, the broader literature on physician communication documents this factor as key in avoiding malpractice suits and managing risk. Two studies develop the evidence for language access as a variable related to risk. Patients with limited English proficiency had significantly more adverse events, such as inaccurate or incomplete information, questionable advice, questionable tracking and follow-up, incorrect diagnosis, and questionable intervention. Hospitalized children of families with language barriers were more likely to experience medical errors than those from families without language barriers.
There is a paucity of research that examines organizational capacity, specifically the existence of culturally and linguistically competent policies, structures, and practices and their impact on increasing market share, cost-benefits, and reducing staff turnover and liability. Little in the literature focuses on the cost-benefits of cultural and linguistic competence to patients, families and communities. Lastly, an essential element of cultural competence is the capacity of an organization to involve patients, families, and their communities systematically in designing, implementing, and evaluating services and supports. None of the methodological approaches used participatory action research models, and patient, community, or key stakeholders were involved only as subjects.
Critical Reflections on the Evidence
The current evidence related to the impact of cultural and linguistic competence on health outcomes and well-being, as well as on cost-benefits to the system, is promising, but is only in the preliminary stages of development. Overall, to move the field forward, the following current limitations must be addressed:
- no consistent framework, logic model or definition for cultural competence that moves the field beyond race or ethnic specific interventions;
- the very narrow scope of current studies in terms of populations, sample size, and length of study periods;
- the impact of funding cycles and priorities that limit the kinds of large size, longitudinal, and broad-based studies that will be needed to establish the evidence base;
- the relative lack of involvement of diverse patients and communities in determining study issues, questions, designs, analysis, and dissemination of results;
- challenges in the complexity of collecting and analyzing data on race, ethnicity, and particularly culture; and
- the political will and public policy needed to support future research on the evidence base for cultural and linguistic competence.
T. D. Goode, M. C. Dunne, and S. M. Bronheim, The Evidence Base for Cultural and Linguistic Competency in Health Care, The Commonwealth Fund, October 2006