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General Surgery. Headache Center. Hyperbaric Medicine. Home Care. Integrative Medicine. Internal Medicine. Infectious Diseases. Using a nationally representative sample of outpatient substance abuse treatment OSAT programs, this study used item response theory to create two measures of cultural competence-organizational practices and managers' culturally sensitive beliefs—and examined their relationship to client wait time and retention using Poisson regression modeling.
Results of regression modeling indicate that organizational practices were not related to either outcome. Managers' culturally sensitive beliefs—considered to be influential for effective implementation of culturally competent practices—may be particularly relevant in influencing wait time and retention in OSAT organizations that treat Latinos and African American clients.
Significant racial and ethnic disparities have been documented in substance abuse treatment Institute of Medicine, Evidence suggests that Latinos and African-Americans are less likely than whites to enter treatment Daley, ; Lundgren et al. While the causes of these problems are complex, there is a growing consensus that organizational cultural competence—defined as a set of practices through which organizations recognize and respond to the needs of culturally diverse populations—represents an important part of the solution Betancourt et al.
Indeed, the new Patient Protection and Affordable Care Act will require health care organizations receiving federal funds, including those providing substance abuse treatment, to enhance cultural competence by setting more rigorous standards for workforce diversity, and cross-cultural training and education Andrulis et al.
Despite growing recognition of the importance of culturally competent service provision in outpatient substance abuse treatment OSAT , conceptualizing and measuring organizational cultural competence has been a persistent challenge for researchers and practitioners alike. Attempts at identifying practices and attitudes that are linguistically and culturally relevant for service outcomes have suffered from several methodological flaws Fisher et al.
Many existing measures of organizational cultural competence have relied upon single case designs or small samples to design measures and test psychometric properties, leading to problems in assessing validity and generalizability Cross, et al.
Others have relied upon expert panels to develop measures, which remain for the most part unvalidated Harper et al. Consequently, there remains a need for measures of organizational cultural competence that are theoretically informed and empirically grounded. In response, this study drew from a nationally representative sample of OSAT organizations to develop two empirically derived measures of cultural competence using Rasch modeling.
Rasch models, which are informed by item response theory, represent a relatively novel approach to measurement development and validation in substance abuse treatment research Henderson et al. We then considered the role of these measures as predictors of program effectiveness by exploring their relationship with treatment wait time and retention—both outcomes of central importance to OSAT organizations.
Prior studies that have attempted to operationalize cultural competence have identified a diverse set of organizational practices, attitudes, and services that can be adapted to enhance the cross-cultural sensitivity and responsiveness of health care organizations Brach and Fraser, ; Fisher et al. These studies have identified several organizational domains in which cultural competent practices can be developed, including organizational governance, program evaluation, communication, human resources, and facilitation of services to clients.
Among the most prevalent and well-recognized practices designed to improve organizational cultural competence across these domains are: 1 race—ethnic matching, defined as treatment by staff of the same racial or ethnic minority group as the client; 2 language congruence, defined as treatment by staff who speaks the primary language of the client; 3 cross-cultural training, which entails providing staff with knowledge and skills regarding the needs, preferences, and beliefs prevalent among specific racial and cultural minority groups; 4 inclusion of family in the treatment process; and 5 collaboration with faith-based organizations during treatment and follow-up.
While much work has focused on defining and conceptualizing organizational cultural competence , standardized and empirically validated comprehensive scales through which to measure organizational cultural competence have been lacking Cross et al.
Among seekers of help for substance abuse, wait time to treatment entry is the most commonly cited barrier to access Appel et al. Empirical research corroborates these claims, suggesting a positive relationship between wait time and pretreatment dropout Claus and Kindleberger, ; Festinger et al. Reflecting its importance to treatment access, wait time has been included in a series of performance measures developed by the Washington Circle Garnick et al.
Yet, relatively little is known about the relationship of organizational cultural competence to client wait time in substance abuse treatment. To our knowledge, no studies have specifically examined the association of cultural competence to client wait time to enter substance abuse treatment.
In the broader field of medicine, research has indicated that language barriers may contribute to longer waiting periods to receive treatment Betancourt, Additionally, it has been suggested that when interpreters or bilingual providers are not readily available, clients in need of such services may wait longer to commence treatment Gonzalez et al. Moreover, research suggests that members of racial and ethnic minority groups are more likely than whites to experience difficulties in navigating the health services system and gaining knowledge about programmatic and financial resources that may facilitate access to treatment Institute of Medicine, Retention in treatment is an important process outcome related to clinical outcomes Grella et al, ; Hubbard et al.
These studies suggest that longer retention is associated with improved substance use outcomes at post-treatment, although the study by Zhang and colleagues suggests that retention may have diminishing returns as length of time in treatment increases. Similar to wait time, aspects of retention in treatment has also been incorporated into performance measures developed by NIATx McCarty et al. Relatively little is known about the nature of this relationship within the context of substance abuse treatment.
Studies in medical settings suggest that organizational cultural competence may improve client retention by providing a more positive treatment experience for clients from racial and ethnic minority groups.
Cultural competence among staff has been linked to better communication, more accurate diagnosis, positive therapeutic alliance, and higher client satisfaction Brach and Fraser, ; Cross et al. Indeed, at least some research suggests that clients from racial and ethnic minority groups may be more likely to remain in treatment when the services they receive are responsive to their needs.
Additionally, some studies using ethnic matching and cross cultural training have documented higher retention in minority clients within the first three weeks of services Sue et al.
Taken together, these studies suggest that organizational cultural competence may help to enhance the quality of OSAT for racial and ethnic minority populations and improve in-treatment outcomes. Yet, the most commonly used measures of organizational cultural competence lack information about psychometric properties. Moreover, relatively little is known about the role of organizational cultural competence in shaping important outcomes in OSAT.
In light of these gaps in the literature, we examine the following research questions in the present study: 1 What cluster of organizational practices and managerial beliefs best represent the latent constructs of organizational cultural competence? Extant research suggests that potential clients from racial and cultural minority groups may have difficulty accessing treatment due to language barriers and lack of culturally appropriate services and informational materials.
Moreover, programs that provide services tailored to the needs of racial and ethnic minorities may be more likely to retain them, particularly if these programs are led by managers with high levels of cultural sensitivity. Managers with greater cultural sensitivity may direct more thorough implementation of culturally competent practices and, consequently, a more accepting and responsive treatment experience for racial and ethnic minority groups.
Thus, we hypothesize the following relationships:. Degree of adoption of culturally competent practices will be negatively associated with average wait time to enter OSAT. Degree of adoption of culturally competent practices will be positively associated with average retention in OSAT.
The sampling frame included several national lists of substance abuse treatment providers. Sampling was stratified by treatment modality, ownership, and organizational affiliation. The total sample included treatment units or programs. Considering only diverse units, the resulting analytic sample included OSAT programs. We examined two dependent variables: 1 client wait time to treatment and 2 client retention in treatment. Retention in treatment was also measured using a single survey item, in which managers were asked to estimate the average number of months clients stay in treatment.
Both variables are count measures in that they represent estimates of number of days or months, accordingly. While these practices do not encompass all culturally competent activities in an organization, these two frameworks are widely used for conceptualizing and measuring culturally competent health care practices. A list of these practices is included in Table 1. Items reflecting organizational practices included cross-cultural training, language congruence, diversity of staff, and availability of same-race individual and group-counseling Brach and Fraser, ; Fisher et al.
Several control variables were included. These included organizational size log of the total number of clients served during the past fiscal year ; location urban or other ; staffing resources log of the ratio of staff to clients ; s ervice comprehensiveness total number of services offered by treatment organization ; treatment modality outpatient counseling or methadone maintenance ; ownership private for-profit, private nonprofit, or public ; and affiliation organization is freestanding or part of a larger mental health or hospital setting.
These variables were selected because they have been shown to be associated with at least one of the treatment outcomes under study in prior literature Carr et al.
A Rasch model was used to investigate the extent to which the data were consistent with the postulated latent construct of organizational cultural competence. The Rasch model relies on fit statistics Outfit and Infit in order to describe the fit of the endorsement patterns to an underlying Rasch model. Outfit captures the average mismatch between the Rasch model and the data considering extreme values, while Infit measures the central performance of each item Linacre and Wright, Using this comparative approach, Rasch modeling indexes items on their difficulty or probability of endorsement Wright and Masters, Items that have higher difficulty lower probability of endorsement reflect more of the latent trait.
This is analogous to conventional measures of intelligence, in which the most challenging items are used to identify the most exceptional respondents. To produce valid fit statistics, the Rasch model requires that items represent one dimension and remain locally independent from each other Wright and Masters, Compared to other measurement methods, Rasch true interval scales can strengthen the accuracy and statistical validity of analysis and help achieve greater generalizability.
The Rasch model produces normally distributed true interval scales, which improve estimates in multivariate regression analysis and allow greater generalization. Items in both measures were introduced in dichotomous scales, as required by the Rasch model. For the culturally competent practices, 6 of the 14 items representing practices were transformed to dummy variables using cutoff points informed by conceptual expectations or empirical generalizations from nationally representative samples.
We recalibrated both measures to a mean of 50 and standard deviations of 10 to facilitate visual interpretation and comparison. Multiple imputation was used to fill in missing values, as data were assumed to be missing at random Little and Rubin, , Rubin, We examined the cross-sectional relationship between cultural competence and the two dependent variables, average retention and average wait time.
To address this issue, a Poisson distribution was assumed with a log link function, an overdispersion parameter, and a specification that allows for a higher-than-expected number of zero values.
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