Culturally And Linguistically Appropriate Services Research Articles

Understanding Professional Medical Interpreters' Perspectives on Advancing Accurate and Culturally Informed Patient-Provider Communication for Filipinos in Hawai'i: Qualitative Analysis.

One in every eight persons in Hawai'i, USA, have limited English proficiency (LEP) and are entitled to free language assistance for federally funded services under Title IV of the Civil Rights Act of 1964. They also have the right to culturally and linguistically appropriate services (CLAS) provided by professional medical interpreters (PMIs). This study's goals were to uncover barriers and facilitators of CLAS from the perspective of PMIs. PMIs for Filipino languages (n = 10) participated in an online survey and semi-structured interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using conventional content analysis. Six themes emerged in the qualitative analysis: (1) cultural and social factors that can influence patient-provider communication; (2) barriers to effective patient-provider communication: patient, healthcare provider, and PMI levels; (3) facilitators of effective patient-provider communication: patient, healthcare provider, and PMI levels; (4) COVID-19 and remote interpreting barriers and facilitators; (5) strengths and weaknesses of in-person and stand-by interpreting appointments; and, (6) recommendations: system and provider levels. Proposed interventions could include advertising language services among Filipino communities and educating them about their language rights, providing additional resources for language assistance, employing more PMIs, training staff/providers, and supporting the use of PMIs versus untrained individuals.

The Impacts of Inclusionary State Immigrant Policies on Psychosocial Outcomes Among Latinx Adolescents

State-level policies that exclude immigrants, primarily undocumented, from public services and benefits have been found to have negative psychosocial impacts on Latinx adults, regardless of nativity. The effects of inclusionary policies-that is, extending public benefits to all immigrants-remain underexamined, as well as the impacts on adolescents. We used data from the Youth Risk Behavior Survey from 2009 to 2019 to examine the association between 7 state-level inclusionary policies and bullying victimization, low mood, and suicidality among Latinx adolescents via 2-way fixed-effects log-binomial regression models. Banning the use of eVerify in employment was associated with decreased bullying victimization (prevalence ratio [PR]= 0.63, 95% CI: 0.53-0.74), low mood (PR= 0.87, 95% CI: 0.78-0.98), and suicidality (PR= 0.73, 95% CI: 0.62-0.86). Extending public health insurance coverage was associated with decreased bullying victimization (PR= 0.57, 95% CI: 0.49-0.67), and mandating Culturally and Linguistically Appropriate Services (CLAS) training for health care workers was associated with decreased low mood (PR= 0.79, 95% CI: 0.69-0.91). Extending in-state tuition to undocumented students was associated with increased bullying victimization (PR= 1.16, 95% CI: 1.04-1.30), and extending financial aid was associated with increased bullying victimization (PR= 1.54, 95% CI: 1.08-2.19), low mood (PR= 1.23, 95% CI: 1.08-1.40), and suicidality (PR= 1.38, 95% CI: 1.01-1.89). The relationships between inclusionary state-level policies and Latinx adolescent psychosocial outcomes were mixed. Although most inclusionary policies were associated with improved psychosocial outcomes, Latinx adolescents residing in states with inclusionary policies related to higher education had worse psychosocial outcomes. Results suggest the importance of elucidating the unintended consequences of well-intentioned policies and the importance of continued efforts to reduce anti-immigrant sentiment.

PAIN, PLACE, AND POSITIONALITY: SYSTEMIC APPROACHES TO IMPROVING EQUITABLE HEALTH OUTCOMES FOR OLDER ADULTS

Abstract Racism and other “isms” are systemic problems that operate across multiple domains and affect access to care and services, available treatments, and long-term health outcomes for older adults. As such, changing these systems requires diverse methodological approaches that can identify and examine the contextual factors that influence these outcomes, along with continued strong advocacy that will result in related policy change. This presentation will highlight challenges in care delivery and outcomes for Black older adults in pain management, COVID care, and long term care placement and examine how mixed methodological approaches and implementation of the Culturally and Linguistically Appropriate Services (CLAS) Standards as outlined by the U.S. Department of Health and Human Services can make a difference.

Promoting culturally and linguistically appropriate services (CLAS): Core leadership competencies

Promoting culturally and linguistically appropriate services (CLAS): Core leadership competencies

Physician Cultural Competency Training and Impact on Behavior: Evidence From the 2016 National Ambulatory Medical Care Survey.

The number of racially and culturally diverse patients in the medical practices of US physicians is increasing. It is unclear how well culturally and linguistically appropriate services (CLAS) standards have been integrated into physician practice. The objective of this study was to determine the prevalence of US-based physicians who received training in cultural competency and describe their behavior. This survey study utilized data from a supplement of the 2016 National Ambulatory Medical Care Survey (NAMCS). The NAMCS Supplement on CLAS for Office-based Physicians (National CLAS Physician Survey) is a nationally representative survey of ambulatory physicians. We determined the proportion and characteristics of physicians who reported receiving cultural competency training in medical school or in practice. The unweighted sample of 363 yielded a weighted sample of 290,109 physicians, 66.3% of whom reported that they had received cultural competence training at some point. Only 35.5% of the sample had ever heard of the CLAS standards, suggesting a low level of awareness of the standards. Further, only 18.7% reported that training in cultural competency is required for newly hired physicians who join their practice. There were no statistically significant differences between those who had been trained and those who had not in terms of self-reported consideration of race/ethnicity or culture in assessing patient needs, diagnosis, treatment and patient education (P>.05). Fewer than half of practicing physicians reported receiving cultural and linguistic competency training in medical school or residency. It is possible that cultural competence training is being seamlessly integrated into medical education.

“Providing care across a language barrier” – A program at the intersection of inter-professional education and co-curricular engagement

Background and purposeAs the number of patients with limited English proficiency (LEP) in the United States grows, so does the importance of finding solutions for the unique challenges that may arise in the healthcare arena. The need for culturally and linguistically appropriate services (CLAS) is clear, and this topic provides fertile ground for interprofessional collaboration both in practice and education. Educational activity and settingThe authors present a description of a six-hour interdisciplinary program offered as a dual continuing education and co-curricular opportunity for faculty, preceptors, and students in health professional programs at one university. The program covered topics related to CLAS, such as Spanish language basics, ethical considerations when language barriers are present, common misconceptions that exist, and strategies and resources to improve care for LEP patients. FindingsA total of 24 participants (four nurses, two nurse practitioners, six pharmacists, two nursing students, and 10 pharmacy students) completed the program. Post-evaluation responses revealed that 94% of participants would change how they cared for patients as a result of the home study, with 80% concordance for each of the live sessions. DiscussionResponses provided helpful feedback for integration of these topics into coursework and on the value of resources for current practitioners, ultimately highlighting the value of an inter-professional training module for delivery of the content. This program was a positively received offering that enhanced inter-professional education and co-curricular offerings on an important topic.

SACRED Connections: A university-tribal clinical research partnership for school-based screening and brief intervention for substance use problems among Native American youth

ABSTRACT Native American (NA) youth report higher rates of alcohol, marijuana, and drug use than U.S. adolescents from any other racial/ethnic group. Addressing this health disparity is a significant research priority across public health, minority health, and dissemination and implementation (D&I) sciences, underscoring the need for empirically-based interventions tailored for NA youth. Effective D&I with NA youth incorporates NA cultural values and involves tribal elders and stakeholders. SACRED Connections (NIDA R01DA02977) was a university-tribal research partnership that utilized a culturally derived Native-Reliance theoretical framework and a community-based participatory research (CBPR) approach. A significant objective of this randomized controlled trial was to close D&I gaps utilizing the RE-AIM Model and National Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care Standards (HHS, 2019). Findings of this 5-year RCT revealed a statistically significant protective relationship between Native Reliance and baseline lifetime and past month alcohol and marijuana use; additionally, the likelihood of reporting marijuana use at 3 months post-intervention was significantly lower among the active condition than among the control condition. Implementation of a developmentally and NA culturally tailored brief protocol revealed: partnering with Native Americans and utilizing CBPR facilitated engagement with this hard-to-reach, underserved community; age and culture are associated with substance use severity among NA teens; a culturally adapted Motivational Interviewing (MI) brief intervention may be effective in reducing marijuana use among NA youth; the Native Reliance theory proved useful as a framework for working with this population; and RE-AIM proved helpful in conceptualizing health equity promoting D&I.

What About Mom? Health Literacy and Maternal Mortality

This study examined health literacy of postpartum education materials assessing readability, understandability and cultural sensitivity using common health literacy measures. Materials examined rated poorly on measures of health literacy and cultural sensitivity using evidence-based measures including the Patient Education Materials Assessment Tool (PEMAT), Fry-based Readability and National Standards for Culturally and Linguistically Appropriate Services (CLAS). Findings suggested a need for health literate and culturally sensitive postpartum education. Materials and an App were developed for new moms to help them identify postpartum warning-signs and appropriate action moms should take to address symptoms or seek emergent care.

School Nurse Cultural Competency Development Using the National CLAS Standards: A Quality Improvement Project

As numbers of culturally diverse students rise, struggles with language, cultural differences, and health care create challenges for school nurses. The focus of this quality improvement project was to utilize the National Standards for Culturally and Linguistically Appropriate Services (CLAS) as a framework to initiate cultural competency development among school nurses. Eighteen public school nurses attended programming that began with the webinar "CLAS is in Session," an introduction to the standards as applicable to school nursing practice. Outcome measures included self-report of cultural awareness and sensitivity (CAS) and culturally competent behaviors (CCB). A greater percentage of nurses reported feeling "somewhat competent" after program completion, though CAS and CCB scores did not significantly change. Despite lack of measurable improvement in CCB, implementation of the CLAS Standards created an important starting point for CC programming.

Patient Experiences with the Use of Telephone Interpreter Services: An Exploratory, Qualitative Study of Spanish-Speaking Patients at an Urban Community Health Center.

Racial and ethnic minorities in the U.S. experience higher incidence of and greater morbidity from chronic disease. Limited English proficiency (LEP) is a known contributor to these health disparities. The Culturally and Linguistically Appropriate Services (CLAS) standards of the U.S. Department of Health and Human Services promote health equity through the incorporation of professional interpreter services. While such services have been shown to improve quality of care, limited data exist on patient perspectives regarding these services. Better understanding patient experiences with telephone interpreter services (TIS), an increasingly used modality for professional interpretation, could elucidate ways of improving care for this population. This study explored Spanish-speaking patient experiences with TIS at an urban community clinic. Qualitative data collected via focus groups was analyzed using content analysis and grounded theory methods. Our findings suggest that TIS are generally well accepted by Spanish-speaking LEP patients. Limited relationship development with providers and physician attitudes toward TIS were among reported barriers to the use of these services.

Adoption of the National CLAS Standards by State Mental Health Agencies: A Nationwide Policy Analysis.

This study reports the extent to which states have adopted the national culturally and linguistically appropriate services (CLAS) standards. Officials from public mental health agencies in the 50 states, Washington, D.C., and Puerto Rico were contacted between January and June 2016 to obtain information about adoption of CLAS standards in current policies. Each policy was coded through thematic analysis to determine its correspondence with any of the 14 national CLAS standards, which are grouped into three domains. Officials from 47 states and territories (90%) responded. Eight states (17%) reported adopting all national CLAS standards. Ten (23%) had adopted no CLAS policies, five (12%) had adopted policies under one domain, three (7%) under two domains, and 25 (58%) under all three domains. Most states do not have policies that meet all CLAS standards, raising questions about how CLAS standards should be adopted.

Health Quality Measures Addressing Disparities in Culturally and Linguistically Appropriate Services: What are Current Gaps?

Disparities in health care persist among many at-risk groups. This study examines the current state of health quality measures addressing disparities and culturally and linguistically appropriate services (CLAS), and identifies important gaps in existing measures and their implementation. We searched key quality reporting databases and websites to identify measures and structural program requirements addressing disparities or CLAS. We also conducted a dozen semi-structured interviews to obtain expert perspectives. Twenty-four measures and eight private or public-sector programs with relevant structural requirements were identified. Half the measures focused on language needs. Few measures were used in national reporting programs and adoption of requirements has been limited. Barriers to implementation included lack of data among health plans, lack of health workforce training, and challenges in defining cultural competence. Future efforts should seek to enhance implementation of existing quality measures addressing disparities and CLAS, and address barriers to their adoption.

Leading Organizational Cultural Competency: Nurse Leader Rounds and Care for Diverse Patients.

Chief nurse executives (CNEs) face challenges in providing high-quality, patient-centered care for diverse populations. Although the implementation of culturally and linguistically appropriate services (CLAS) may improve patient satisfaction, the cost of initiatives and education coupled with shortened episodes of care pose obstacles. The article describes themes from a qualitative study with CNEs, describes resources and best practices, and highlights nurse leader rounds as a vehicle for implementing CLAS.

Assessment of National CLAS Standards in Rural and Urban Local Health Departments in Kentucky.

Findings from the Centers for Disease Control and Prevention suggest that addressing persistent health disparities based on race and ethnicity must become a national priority. The field of cultural and linguistic competency has gained national attention by improving access to and quality of health care, patient-provider communication, health outcomes, and health equity for minority groups and other vulnerable or special needs populations. (1) To measure how local health departments (LHDs) in Kentucky comply with the National Standards for Culturally and Linguistically Appropriate Services (CLAS); and (2) to provide policy recommendation based on the findings. This study is the first to assess a statewide public health system under the lens of CLAS. Analysis of cross-sectional survey. Electronic surveys administered to LHD administrators in Kentucky. Public health directors, nurse leaders, and program managers. Levels of compliance with various CLAS standards were examined for rural and urban counties using a novel scoring method. A total of 159 LHD administrators received the survey. Response rate was 67% (106 participants). Rural and urban LHDs achieved moderate compliance on domains of plans and policies, quality monitoring and improvement for needs assessment, management information systems for clients, and staff training and development. Both geographic groups exhibited lesser compliance on domains of organizational governance, culturally inclusive health care environment for educational materials, and diversity of personnel recruitment. County and district LHDs in Kentucky have implemented activities and policies that comply with CLAS standards at levels that vary by domain. Areas requiring particular attention include organizational governance, culturally inclusive health care environment for educational materials, and diversity of personnel. Improvements in these areas may help LHDs better meet the needs of vulnerable populations, racial and ethnic minorities, and special needs groups. CLAS practices may allow organizations to adhere to national public health accreditation standards.

Literature Review of the National CLAS Standards: Policy and Practical Implications in Reducing Health Disparities.

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care are a practical tool for health and health care organizations to improve their provision of culturally and linguistically appropriate services (CLAS). Published by the Office of Minority Health at the U.S. Department of Health and Human Services, the National CLAS Standards provide health and health care organizations with a set of action steps for better meeting the needs of individuals from culturally and linguistically diverse backgrounds. Few studies have examined the concept of CLAS or the National CLAS Standards, and they have rarely been extensively studied or reviewed. The authors conducted three literature searches between February 2014 and May 2015, examining the organizational challenges, applicability, and policy implications related to the National CLAS Standards or CLAS, and selected 55 articles for inclusion in the review. The literature highlights a number of challenges in implementing the National CLAS Standards and/or providing CLAS, including issues related to the communication within health care organizations and the inconsistency of accountability measures. This literature review contributes to the growing knowledge base of the National CLAS Standards and CLAS in health and health care.

Design and evaluation of interprofessional cross-cultural communication sessions

The 2013 National Standards for Culturally and Linguistically Appropriate Services (CLAS) call for healthcare professionals to provide quality care and services that are responsive to diverse cultural health beliefs and practices. Accreditation organizations for health professional programs require their curriculum to adequately prepare future practitioners for serving culturally and linguistically diverse populations. Another common curricular need of health professional programs is interprofessional education (IPE). This study presents data that evaluates two IPE culturally competent communication sessions designed for pharmacy and nursing students. Teams of nursing and pharmacy students (n = 160) engaged in case studies focused on developing cross-cultural communication skills, using the LEARN model. Quantitative survey data collected pre-test and post-test measured cultural competency (including subscales of perceived skills, perceived knowledge, confidence in encounter, and attitude) and knowledge related to culturally competent communication. Univariate ANOVA results indicate that actual knowledge as measured by the test and all four Clinical Cultural Competency Questionnaire (CCCQ) subscales significantly increased after the IPE sessions. Pharmacy students scored higher than nursing students on the knowledge pre-test, and nursing students had a more positive attitude at pre-test. The IPE sessions effectively addressed all learning outcomes and will continue in future course offerings. Using cross-cultural communication as a thematic area for IPE program development resulted in educational benefits for the students. To further strengthen nursing and pharmacy students’ interprofessional practice, additional IPE opportunities are to be explored.

A Scoping Review of the Literature: Content, Focus, Conceptualization and Application of the National Standards for Culturally and Linguistically Appropriate Services in Health Care

With the aim of addressing inequalities and disparities in health care access and outcomes, in 2001 the United States Department of Health and Human Services Office of Minority Health (OMH) established National Standards for Culturally and Linguistically Appropriate Services (CLAS). In 2010 the OMH solicited public, private and government input which was incorporated into the Enhanced National CLAS Standards. To date there have been no formal reviews of the published literature on the CLAS Standards. The aim of this scoping review was to identify the scientific and professional literature related to the CLAS standards and describe the content, focus, conceptualization and application of these publications, with the goal of providing insights and directions for further research and application of the CLAS standards.

Could Values and Social Structures in Singapore Facilitate Attainment of Patient-Focused, Cultural, and Linguistic Competency Standards in a Patient-Centered Medical Home Pilot?

Primary care practices in the United States are transforming into patient-centered medical homes (PCMHs) at a rapid pace. Newer PCMH standards have emphasized culturally and linguistically appropriate services (CLAS), but at this time, only some states in the United States have proposed or passed cultural competency training for health care professionals. Other countries are moving to PCMH models. Singapore, a small, ethnically diverse island nation, has national values and social structures that emphasize cultural and linguistic cohesion. In this piece, we examine Singapore’s first PCMH pilot with a national academic center and primary care practice group. Features such as common shared values, self-reliance, racial and religious harmony, patient experience surveillance, and incorporation of CLAS standards in routine health care transactions may predict success for the PCMH in Singapore, with some implications for the United States.

The Place of 'Cultural Competency' in the Toolkit for Immigrant Integration

The purpose of this paper is to trace the evolution of the concept and practice of “cultural competency” and to explore its potential to serve as an organizing principle for policies and programs to integrate immigrants and their children. As some leaders and policy makers look for ways to “mainstream” immigrant integration, i.e. move away from stand-alone immigrant service programs, cultural competency -- understood as an approach to systems reform and quality improvement in workforce education, health care, and human services in general -- may provide an attractive solution.The goal of cultural competency in health and human services emerged in the 1960s as an outgrowth of the Civil Rights Revolution in the United States. The leaders of the cultural competency movement were concerned about inequities in the quality and availability of services and resources for Black and other long-established minorities. They also sought to validate minority cultures and harness the potential of these cultures to build stronger communities and empower people to achieve their potential. Over time, the cultural competency frame has been adapted to meet the needs of the growing immigrant population in the U.S. Several significant milestones along the way include the issuance of executive order 13116 by President Clinton in 1999, which led to the codification of requirements for language access accommodations, and the release of the first standards for Culturally and Linguistically Appropriate Services (CLAS) by the Department of Health and Human services in 2002. More significantly, researchers have struggled to define the meaning of cultural competency and to develop standards for evaluating an organization’s progress on the “cultural competency continuum.” At the same time, there has been a significant shift away from an earlier emphasis on staff training, values clarification, and individual transformation to a new effort to identify the system requirements for cultural competency. Cultural competency offers several advantages as a framework for immigrant integration: first, it encompasses generations beyond the immigrant generation, hence incorporating native-born citizens into its reach; second, it speaks to the needs of long-established minority populations, such as Blacks in the United States; third, it expands outward to include other forms of diversity, including disability, class, and region; and fourth, it speaks to the globalization of contemporary societies and the importance of cultural sensitivity as a way of interacting with diverse populations. The paper will probe each of these advantages, as well as arguments that might be raised against the pursuit of cultural competency by “multicultural skeptics.” In summary, this paper will trace the evolution of the concept of cultural competency, give examples as to how it has proven useful in designing services for immigrant communities, and describe an emerging consensus on system requirements for cultural competency, as reflected in the revised CLAS standards issued in 2013 and in such projects as the “Finding Answers” program of the Robert Wood Johnson Foundation, which funded 33 projects to test interventions to reduce disparities in health care, many of which targeted immigrant populations in the U.S. The paper will also assess the utility of cultural competency as a strategy for mainstreaming immigrant integration.

Addressing disparities in mental health agencies: strategies to implement the National CLAS Standards in Mental Health.

Historically, the mental health system has not effectively addressed the needs of culturally and linguistically diverse individuals (President's New Freedom Commission on Mental Health, 2003), which has contributed to significant racial and ethnic disparities in mental health care (USDHHS, 2001). This paper focuses on exploring how a U.S. Department of Health and Human Services' Office of Minority Health policy initiative, the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (or the National CLAS Standards), may be used by mental health agencies to reduce mental health care disparities. The National CLAS Standards are a set of action steps that inform and facilitate the implementation of culturally and linguistically appropriate services. We first discuss the role of cultural and linguistic competency in mental health care disparities reduction efforts, and then describe specific strategies to facilitate the organizational implementation of the National CLAS Standards.