Developing a Self-Assessment Toolfor Culturally - Office of Minority ...

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CHAPTER 1: INTRODUCTIONThis report presents the results of the project Developing a Self-Assessment Tool forCulturally and Linguistically Appropriate Services in Local Public Health Agencies,sponsored by the U.S. Department of Health and Human Services’ (DHHS) Office ofMinority Health (OMH). The project’s objective was to construct an organizational selfassessmenttool for Local Public Health Agencies (LPHAs) that offers sound measures ofculturally and linguistically appropriate services (CLAS). In this project, the term LPHA isdefined as a publicly funded entity (i.e., local health department, local board of health, andother local government organization) responsible for providing essential public healthservices within a specific jurisdiction. 1 In addition, CLAS are defined as health careservices that are respectful of, and responsive to, the specific needs and preferences ofracially, ethnically, culturally, and linguistically diverse populations (OMH 2001). Theself-assessment tool and corresponding data collection protocols generated by the projectwere developed around a conceptual framework of CLAS conceived in a recent OMHsponsoredstudy which produced a similar tool for collecting data from private-sectorhealth care entities—the National Study of Culturally and Linguistically AppropriateServices in Managed Care Organizations (OMH 2003b). 2The U.S. public health care system continues to be challenged by rapid and significantchanges in the structure of health care delivery as well as by the increasing cultural andlinguistic diversity of the populations served (Anderson et al. 2003). Various organizationsand political and economic realities are transforming public health’s traditional corefunctions. For instance, market-driven health care is forcing public health to clarify andstrengthen its public role in a now predominantly private system (Institute of MedicineIOM 1996). Projections from the 2000 Census indicate that racial and ethnic minoritieswill comprise nearly 50 percent of the U.S. population by 2050 (U.S. Bureau of the Census2001). Also, residents of the U.S. speak an estimated 329 languages, and 32 million speaka language other than English at home (Smith and Gonzalez 2000). Given this trend, theprovision of CLAS by LPHAs will continue to be of increasing importance because of thehigh proportion of racial and ethnic minorities served by LPHAs, the wide range ofservices they provide, and the critical role they play as safety net providers to the country’scommunities.1 The term LPHA was defined by the project’s expert panel to help differentiate it from a local healthdepartment (LHD), which does not fully capture all local, publicly funded organizations responsible forproviding essential public health services.2 While the original intent of the LPHAs project was to mirror the CLAS in MCOs study by developingand administering the tool to a representative sample of LPHAs, the project objectives and timeline weremodified due to shifts in departmental priorities.COSMOS Corporation, December 2003 1-1
While many LPHAs currently provide CLAS to their clients in some form, studiesindicate that CLAS are delivered in ad hoc fashion, vary significantly in their quantity andquality (Association of State and Territorial Health Officials ASTHO 1992; Mertz andFinocchio 1999), and reflect differing views of what constitutes “culturally andlinguistically appropriate health care services” (U.S. Conference of Local Health Officers1993). Studies have shown that racial and ethnic minorities and persons with limitedEnglish proficiency (LEP) many times do not receive adequate services, and have to relyon family members, friends, or strangers who are not trained in the use of medicalterminology to guide them through a medical encounter (Milne 2000; National Associationof County and City Health Officials NACCHO 1992). This is important because it isreported that 25 to 50 percent of words and phrases are incorrectly relayed in ad hocinterpretations, which significantly impacts the effectiveness and quality of health careservices (Interpreter Standards Advisory Committee 1998). Therefore, it was the project’sgoal to aid LPHAs by operationally defining CLAS in a systematic manner and provide anappropriate tool to help them collect important information about the extent of their CLASprovision.The remainder of this chapter presents current research that identifies evidence ofpersistent health disparities for racial and ethnic minorities, describes the important rolethat LPHAs play within the U.S. public health system, and describes the background underwhich the project was conceived. Chapter 2 presents the project’s methodology, whichincludes a review of the literature and relevant tools (that guided the revisions to theinstruments); the conceptual framework adopted from the CLAS in MCOs study; and theprocess employed to develop and revise the self-assessment tool. Chapter 3 reviews theresulting instruments which comprise the self-assessment tool, as well as recommendationson how to effectively use the tool.1.1 EVIDENCE OF PERSISTENT DISPARITIES IN HEALTH STATUS ANDHEALTH CARE QUALITYDespite steady improvements in the overall health of the nation, studies conducted inthe last decade confirm that racial and ethnic minorities continue to experience many healthdisparities (DHHS 1991; HRSA 2000). For instance, between 1997 and 1999, the infantmortality rate was highest for infants of non-Hispanic African American mothers (Pastor etal. 2002), and the infant mortality rate for African Americans was more than twice that ofwhites (Cohen and Goode 1999). Moreover, in 1999, age-adjusted death rates for theAfrican American population exceeded those for the white population by 38 percent forstroke, 28 percent for heart disease, 27 percent for cancer, and more than 700 percent forHIV disease (Pastor et al. 2002).In addition, rates for all types of cancer are higher for African Americans than forwhites (DHHS 1991), and although African American and white women are screened forCOSMOS Corporation, December 2003 1-2
Page 1 and 2: Developing a Self-Assessment Toolfo
Page 3 and 4: ContentsChaptersPage1. Introduction
Page 5: Chapter 1Introduction
Page 9 and 10: LPHAs include: adult and child immu
Page 11 and 12: Professions Education Partnership A
Page 13 and 14: Chapter 2Methodology for Developing
Page 15 and 16: Public Health Practice Program Offi
Page 17 and 18: assess their own beliefs and have k
Page 19 and 20: communicate with, and clearly under
Page 21 and 22: 2.1.6 Identifying Key Components of
Page 23 and 24: Given these persistent disparities
Page 25 and 26: (Exhibit 2-2, Continued)DOMAIN / KE
Page 27 and 28: limited to the actual clinical enco
Page 29 and 30: Chapter 3Project Results and Recomm
Page 31 and 32: local board of health. PEP and PAG
Page 33 and 34: numerous promising CLAS practices a
Page 35 and 36: References
Page 37 and 38: Becker, M.H., and L.A. Maiman, “S
Page 39 and 40: Frye, B., “Health Care Decision M
Page 41 and 42: Marin, G., “Defining Culturally A
Page 43 and 44: Perkins, Jane, “Overcoming Langua
Page 45 and 46: U.S. Bureau of the Census, “Censu
Page 47 and 48: Appendix AMembership Lists of the P
Page 49 and 50: Appendix A-1Developing a Self-Asses
Page 51 and 52: Appendix A-2Developing a Self-Asses
Page 53 and 54: Appendix B-1Overview of Eight CLAS
Page 55 and 56: Domain 3: Culturally Inclusive Heal
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understanding of diversity issues i
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Appendix B-2Conceptual Framework fo
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Appendix CLPHA Director or Designee
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Pre-Interview Script for LPHA Direc
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3b. Which of the following are refl
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6. Does your agency have a formal p
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10. Which of the following describe
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Post-Interview Script for LPHA Dire
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Appendix DStaffing Questionnaire
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A. QUALITY MONITORING AND IMPROVEME
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B. MANAGEMENT INFORMATION SYSTEMS (
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7. Please indicate, if you know, th
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1c. Please indicate for which categ
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6. Please indicate for which catego
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10. Which of the following topical
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17. Which of the following benefits
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4. Which of the following strategie
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Appendix EClient Services Questionn
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A. QUALITY MONITORING AND IMPROVEME
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6b.Which of the following community
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3. Please report or estimate what p
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3. Which of the following practices
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Oral Interpretation Services10. Whi
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16. At which of the following key e
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3. Which of the following kinds of
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Appendix FPilot Test Response Form
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RESPONDENT EVALUATIONOF THE QUESTIO
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Appendix GCLAS in MCOs Study Data C
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position, as titles will likely var
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complex and uncertain at the time t
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1. Incorporate a confirmation pre-c
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Exhibit 2DATA COLLECTION PROCESSSen
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