Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2013 Feb 1.
Published in final edited form as: Eval Program Plann. 2012 Feb 1;35(1):9–15. doi: 10.1016/j.evalprogplan.2011.06.001

Organizational Characteristics that Foster Early Adoption of Cultural and Linguistic Competence in Outpatient Substance Abuse Treatment in the United States

Erick G Guerrero
PMCID: PMC3176458  NIHMSID: NIHMS312084  PMID: 21949458

1. Introduction

Cultural competence—through which organizations recognize and are responsive to the service needs of culturally diverse populations—has become a widely supported policy innovation designed to contribute to reductions in health disparities among minorities. Specifically, concerns about the gradual increase in minority patients in substance abuse treatment (Office of Applied Studies, 2007) and their poor treatment outcomes (Wells, Klap, Koike, & Sherbourne, 2001) have justified efforts to develop a culturally and linguistically responsive system of care in the United States (Campbell & Alexander, 2002; Center for Substance Abuse Treatment, 2009b; Howard, 2003a, 2003b). It is not clear, however, the extent to which these efforts help develop an effective system of linguistic and cultural competence among outpatient substance abuse treatment (OSAT) organizations in the nation.

For the past two decades, federal and state campaigns, as well as professional associations, have encouraged health providers to improve the quality of care for members of culturally diverse backgrounds by providing services sensitive to differences in race, ethnicity, and language (Agency for Healthcare Research and Quality, 2010; OAS, 2009; Ulmer, McFadden, & Nerenz, 2009; Wilson-Stronks & Galvez, 2007). Yet these federal and state policies had vague descriptions of culturally competent practices and lacked enforcement components (Stork, Scholle, Greeno, Copeland, & Kelleher, 2001). Current initiatives emerging from health care reform request providers to collect information on clients’ race, ethnicity, and language proficiency (Ulmer et al., 2009), and plan to fund and monitor providers’ investment in workforce diversity, cross-cultural training, and cultural competence education (Andrulis, Siddiqui, Purtle, & Duchon, 2010). These policy initiatives and directives have been based on little empirical evidence about the organizational factors related to the provision of culturally competent care.

Government policy initiatives began pressuring health care programs as early as 1964 (Title VI) to offer services to minorities based on language and ethnic culture (National Center for Cultural Competence, 2010). But it was not until 1986 that the U.S. Department of Health and Human Services created the Office of Minority Health (OMH), while the Culturally and Linguistically Appropriate Services (CLAS) standards weren’t developed until the mid-1990s (Betancourt, 2004; NCCC, 2010). Concurrently, Medicaid, through the Americans with Disabilities Act as well as the quality assurance rules in the Balanced Budget Act, also defined specific strategies for culturally and linguistically competent care (Stork et al., 2001). The creation of CLAS standards and legislation prompted The Joint Commission (TJC) to incorporate CLAS into its professional accreditation requirements (Wilson-Stronks & Galvez, 2007). Meanwhile, in the early 1990s, academic institutions began to establish teaching and practice standards around CLAS principles to train service professionals to address the health needs and disparities experienced by minority populations in the United States (See Betancourt, 2004; Zane, Gordon, Sue, Young, & Nunez, 2004).

Organizational frameworks on policy innovation point to the need for early buy-in from organizational decision-makers to achieve adoption (CSAT, 2009a; Klein & Sorra, 1996; Simpson & Flynn, 2007). Adoption is just the first stage of the process of implementation (Roman, Ducharme, & Knudsen, 2006; Simpson & Flynn, 2007), and relies on organizations offering new services, technology, or practices. Implementation goes beyond simply having an innovation to making it a routine, using the new practices frequently (Klein & Sorra, 1996). Considering that the cultural competence regulatory movement began in the early 1990s, this study focuses on the organizational factors associated with adoption of culturally and linguistically responsive practices in OSAT programs during that early stage. It examines the direct relationship between the initial presence of regulation and the extent to which programs respond to this early pressure by adopting, at various degrees, culturally and linguistically competent practices. Additionally, the study will determine whether the level of professionalization of an organization is related to the degree of adoption of this policy innovation, and to what degree managers’ cultural sensitivity plays a role in fostering the adoption of culturally and linguistically responsive practices. By examining the major external and internal organizational influences of the early adoption process, this study identifies baseline measures that may inform both future research on cultural competence and relevant components for current health care management policy.

2. Conceptual framework

Prior research highlights the importance of resources and regulatory expectations in the adoption of new health and social service practices in OSAT programs (Campbell & Alexander, 2002, 2005; D’Aunno, 2006; Durkin, 2002). It is evident that programs are pressured by professional and state regulatory bodies to provide linguistic and cultural services to minorities (Wilson-Stronks & Galvez, 2007; Stork et al., 2001). The relationship between organizations and their environmental demands is partially explained by neo-institutional theory. According to this framework, OSAT organizations are institutionalized because they are prone to adopt socially accepted practices in order to gain external resources and legitimacy from government agencies and regulatory licensing and accreditation entities (Campbell & Alexander, 2002; D’Aunno, 2006; DiMaggio & Powell, 1983). By complying with institutional demands and endorsing macrocultural ideals with public cachet, managers obtain necessary resources and professional support for their organizations (DiMaggio & Powell, 1983; Scott, 2001). Yet, rather than passively absorbing institutional mandates, managers may strategically choose the degree of adoption of institutional directives that offer the most resources (Oliver, 1991; Peyrot, 1991). Additionally, regulatory demands, also present in public funding, are generally considered a facilitator in the adoption of innovative practices (Hasenfeld, 1983).

Research shows that regulation that includes specific guidelines and compliance monitoring may have the most receptivity in OSAT programs. For example, the concrete definition of health services and the consistent oversight of its integration in service provision may explain its high degree of adoption among OSAT programs. For instance, OSAT programs with professional accreditation from regulators such as The Joint Commission are more likely to offer new medical services (Campbell & Alexander, 2005; Campbell, Alexander, & Lemak, 2009; Durkin, 2002; Marsh, Cao, & D’Aunno, 2004; Pollack, D’Aunno, & Lamar, 2006; Roman et al., 2006). Despite the fact that regulation regarding cultural competence was ambiguous and poorly monitored in the early 1990s (Stork et al., 2001), OSAT providers reported significant early support for matching clients and providers based on language and race/ethnicity (Guerrero, 2010). OSAT programs with greater dependence on public funding face more pressure to provide services to women (Campbell & Alexander, 2002, 2005) and other minorities (Howard, 2003a, 2003b). Thus, Hypothesis 1 predicts that OSAT programs with a higher presence of regulation and public funding will report a higher degree of adoption of culturally and linguistically competent practices.

According to institutional theory, pressure to offer legitimate practices also stems from professional associations that regulate training for graduate professional degrees (Scott, 2001; Scott, Ruef, Mendel, & Caronna, 2000). In the OSAT field, openness to adopt evidence-based practices has been associated with OSAT providers with higher education levels (Knudsen & Roman, 2004; Wells, Lemak, & D’Aunno, 2006. Although the relationship between graduate education and the incorporation of innovative practices in substance abuse treatment is inconclusive (Miller, Sorensen, Selzer, & Brigham, 2006), professional environments may be more conducive to evidence-based, culturally responsive treatment. Graduate education in the health care professions includes cross-cultural training and ethics, creating service expectations for healthcare providers to develop cultural competency (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Due to these expectations, professional staff, represented here as treatment providers with higher academic education may be more inclined to foster an organizational culture of integrating linguistic and cultural competence. Thus, accounting for funding and regulation, Hypothesis 2 posits that OSAT programs with higher professionalism will exhibit a higher degree of adoption of culturally and linguistically competent practices.

The organizational literature suggests that regulatory institutions influence the adoption priorities of decision-makers through the promotion of institutionally endorsed practices (Thornton & Ocasio, 2007). Initial evidence in substance abuse treatment research suggests that external pressures from stakeholders facilitate early adoption of evidence-based practices, yet meaningful adoption and implementation requires buy-in from leaders and staff (CSAT, 2009a, 2009b; D’Aunno, 2006; Simpson & Flynn, 2007). There is limited evidence on the unique contribution of government resources and regulation in the early adoption process of culturally responsive practices (Guerrero, 2010). However, it is conceivable that the organizational culture that this regulation initially fosters may incentivize some programs to invest in a higher degree of adoption. All providers have a professional responsibility to develop services that meet the cultural and linguistic needs of their client population (CSAT, 2006; 2009a). Yet providers’ commitment to meaningful adoption may be most likely in OSAT programs with higher professionalism and cultural sensitivity. Thus, Hypothesis 3 posits that professionalism and manager’s cultural sensitivity will contribute above and beyond the main effect of funding and regulation to the degree of adoption of culturally and linguistically competent practices in OSAT programs.

3. Methods

This study relied on the National Drug Abuse Treatment Services Survey (NDATSS) dataset, a nationally representative sample of OSAT units. Outpatient services are the most common treatment modality in the United States, serving more than 65% of all clients that enter substance abuse treatment (D’Aunno, 2006), and NDATSS is the most comprehensive survey on the organization and structure of OSAT programs (D’Aunno, 2006).

3.1. Sampling Frame and Data Collection

The sampling frame of the NDATSS was a composite of several national lists of substance abuse treatment providers in the United States. This list provided the framework for drawing random samples stratified by treatment modality (methadone, non-methadone), ownership (public, private for-profit, nonprofit), and organizational affiliation (hospital, mental health center, free-standing program). The NDATSS dataset defined an OSAT unit as any program in which outpatient substance abuse treatment constituted at least 50% of services. More than 80% of directors and clinical supervisors responded to the survey via phone. Directors provided information on organizational structure, while supervisors (referred to here as managers) provided information on their belief systems, as well as information on staff, clients, and practices. For specific information on the sampling approach, see the technical report (Adams & Herringa, 2001).

3.2. Sample

This study used only one wave (the fourth) of six waves completed for the NDATSS project. Wave four, collected in 1995, contained 618 programs and is the only wave with complete data on culturally competent practices. Although this relevant wave was completed 15 years ago, NDATSS remains the only nationally representative sample of the provision of culturally competent practices in the OSAT field, and the only data available to explore the early adoption of these new practices.

3.3. Measures

Dependent variable

In examining the degree of adoption of culturally and linguistically competent practices, 14 practices were identified in the NDATSS that approximated Brach and Fraser’s (2000) comprehensive representation of organizational cultural competence. While this measure focused on practices rather than policies, it included the most significant domains identified in comprehensive reviews (Brach & Fraser, 2000; Fischer, Burnet, Huang, Chin, & Cagney, 2007). Specifically, managers were asked: (1) what percentage of staff completed cross-cultural training; (2) how many mean hours of cross-cultural training staff receive annually; (3) whether their unit has staff who speak Spanish; and (4) whether their unit offers provider/client same-race individual counseling services. In addition to these core culturally competent practices (Campbell & Alexander, 2002), this study included 10 other ethnoculturally relevant practices to approximate a comprehensive conceptual notion of cultural competence (Brach & Fraser, 2000; Howard, 2003a, 2003b). Indicators of these practices include: (1) ratio of African American staff to African American clients; (2) ratio of minority staff to minority clients; (3) percentage of staff self-described as Latino; (4) percentage of staff self-described as African American; (5) whether the unit’s director is African American; (6) whether the unit’s supervisor is Latino; (7) whether the unit does outreach specifically for minorities; (8) whether the unit involves churches in follow-up; (9) whether the unit is affiliated with community-based outreach programs; and (10) whether the unit seeks input from community leaders. The current study used Rasch rating scale analysis with the above indicators to build a unidimensional and continuous composite measure of degree of adoption.

The Rasch method was used as a measurement approach in order to respond to the multidimensional characteristics of the survey data. Rasch models represent a relatively novel approach to measurement development and validation in substance abuse treatment research (Henderson, Taxman, & Young, 2008). Using principles of item response theory, Rasch analysis converts a set of dichotomous variables into equal-interval scales (Wright & Masters, 1982). This method provides information on both respondents’ likelihood to answer different items and the ability of items to describe a single concept. Combining these two pieces of information results in an outcome measure that is linear, unbiased by particular items or units in the analysis, and robust to missing data (Wright & Masters, 1982).

The continuous outcome measure developed in this study was labeled “degree of adoption of linguistic and cultural competence.” Four original items (practices) were removed because of their high correlation with other items; namely, whether the unit had a Latino director, African American supervisor, and/or bilingual staff, as well as the ratio of Latino staff to clients. After removing these items, this measure showed optimal psychometric properties; respondents differentiated practices from each other adequately (separation = 11.10) and practices were highly interrelated (Cronbach’s reliability coefficient = .79). For measurement development details, see (Guerrero & Andrews, in press).

Independent variables

Resources and regulation variables included two funding measures associated with provision of health care practices: (1) public revenue, measured as the percentage of total public funding received by the facility in the last fiscal year, and (2) revenue for minority services, measured as funding specifically earmarked for services for racial/ethnic minorities. Regulation measures included three items: (1) state license, (2) city license, and (3) accreditation—specifically, whether the program is accredited by The Joint Commission. While TJC enforces professional norms, it largely functions as an external regulatory entity. Professionalism was measured as staff with graduate degree, or the percentage of unit staff with a master’s degree, PhD, or MD.

Finally, the measure of managers’ cultural sensitivity was also developed using Rasch measurement methods. This measure represented managers’ degree of support for the cultural and language service needs of Latino and African American clients. Managers were asked about the extent to which they agree that, compared to Caucasians, African American or Latino clients need: (1) treatment by staff of the same ethnic minority group; (2) treatment by staff educated in the history of that group; (3) treatment by staff who speak their language or dialect; and (4) treatment by staff who provide special services. Managers’ responses indicated that they adequately differentiated each belief (separation = 10.50), and the measure reported a Cronbach’s reliability coefficient of .99.

Control variables

The empirical and theoretical literature points to important factors that serve as alternative explanations of the relationship between external and internal organizational characteristics and the provision of culturally responsive practices. The organizational structure, ownership, and affiliation of programs, as well as proxies for client racial/ethnic diversity, were included as control variables in this study.

Organizational structure

Organizational size corresponds to the capacity to serve clients, measured as the log of the total number of clients served during the past fiscal year. Staffing resources indicates the level of staffing available to serve a diverse population (Guerrero, 2010), and was measured as the log ratio of the total number of treatment staff and clients during the previous fiscal year. Organizational size and staffing resources were transformed to logarithms to reduce potential for collinearity with other variables, and centering was necessary to ease interpretation of coefficients representing the average size and staffing resources of OSAT programs. Service comprehensiveness was also considered in this study, as programs with more services are more likely to integrate more practices (Friedmann, D’Aunno, Jin, & Alexander, 2000). This was a count measure of the total number of services the program provided. Treatment modality was included due to the differing structure of outpatient programs based on the type of drug treatment services provided—namely, the difference between methadone and non-methadone providers. Methadone programs are more regulated than non-methadone, partially due to the use of pharmacotherapy (D’Aunno & Pollack, 2002). Location was also considered due to the fact that urban programs tend to have more capabilities, more pressure to adopt legitimate practices (D’Aunno & Pollack, 2002; Pollack et al., 2006), and more access to cultural diversity (Howard, 2003a, 2003b). Location was measured in terms of whether the unit was located in a metropolitan area or not.

Other characteristics of programs also shape the extent to which they have the organizational culture or external pressure to offer culturally responsive practices. Ownership represents a key component because public treatment centers, as compared to privately owned facilities, are more responsive to federal and state expectations and more likely to offer safety-net care (D’Aunno, 2006; Howard, 2003a). This concept was represented by dummy variables that, using government-run public programs as a reference, represented whether the unit was private for-profit or private nonprofit. Affiliation represents programs that are part of a larger mental health or hospital setting, and dummy measures were created using free-standing programs as a reference. In contrast with mental health and hospital settings, developing evidence suggests that freestanding facilities are more likely to adopt a variety of culturally responsive practices (Guerrero, 2010). Finally, client racial/ethnic diversity was included because diverse programs are likely to have diverse staff and offer culturally (Howard, 2003a) and linguistically responsive services (Guerrero, 2010). These variables included three levels (low, medium, and high) based on Latino and African American clients’ average representation in the OSAT field. See Table 1 for descriptive statistics and response format for variables used in the study.

Table 1.

Descriptive statistics and response format

Variables 1995 (N = 618) Response format
Dependent variable
 Degree of adoption of culturally and lingjuistically competent practices, M (SD) 40.93 (10.67) Rasch composite measure of 14 practices considered culturally responsive (ranges from 0 to 100)
Independent variables
 Public revenue, M (SD) 55.8 (37.0) % of total budget in last fiscal year
 Revenue for minority services (%) 5.1 1 = Unit has specific revenue to serve minority clients
0 = Unit does not have specific revenue to serve minority clients
 State license (%) 92.3 1 = Unit has a state license
0 = Unit does not have a state license
 City license (%) 15.5 1 = Unit has a city license
0 = Unit does not have a city license
 Accreditation (TJC) (%) 24.6 1 = Unit has TJC accreditation
0 = Unit does not have TJC accreditation
 Staff with graduate degree, M (SD) 32.8 (32.9) Percentage of treatment staff with a graduate degree
 Manager’s cultural sensitivity, M (SD) 55.6 (20.0) Rasch composite measure of six beliefs regarding the service needs of Latinos and African Americans (ranges from 0 to 100)
Control variables
Client racial/ethnic diversity
 High – Latino/a (%) 17.7 1 = > 30% of total clients are Latino/a
0 = < 30% of total clients are Latino/a
 Medium – Latino/a (%) 33.8 1 = 6% to 30% of total clients are Latino/a
0 = 6% to 30% of total clients are not Latino/a
 Low – Latino/a (referent) (%) 48.5 1 = < 6% of total clients are Latino/a
0 = > 6% of total clients are Latino/a
 High – African American (%) 24 1 = > 40% of total clients are African American
0 = < 40% of total clients are African American
 Medium – African American (%) 33.5 1 = 10% to 40% of total clients are African American
0 = 10% to 40% of total clients are not African American
 Low – African American (referent) (%) 42.5 1 = < 10% of total clients are African American
0 = > 10% of total clients are African American
Organizational structure
 Unit size (number of clients), M (SD) 347 (754) Number of total clients served past fiscal year (logarithm and mean-centered in analyses)
 Staffing resources, M (SD) 0.2 (0.2) Ratio of staff to clients (logarithm and mean-centered in analyses)
 Service comprehensiveness, M (SD) 12.1 (6.4) Ranges from 0 to 26
 Methadone (%) 20.7 1 = Unit is a methadone provider
0 = Unit is not a methadone provider
 Urban unit (%) 48.9 1 = Unit is within metropolitan area
0 = Unit is not within metropolitan area
Ownership
 For-profit (%) 13.9 1 = Unit is for-profit
0 = Unit is not for-profit
 Nonprofit (%) 62.3 1 = Unit is nonprofit
0 = Unit is not nonprofit
 Public (referent) (%) 23.8 1 = Unit is public
0 = Unit is not public
Affiliation
 Hospital (%) 18.3 1 = Unit is affiliated with hospital
0 = Unit is not affiliated with hospital
 Mental health facility (%) 22.5 1 = Unit is affiliated with mental health center
0 = Unit is not affiliated with mental health center
 Free-standing unit (referent) (%) 59.2 1 = Unit is free standing
0 = Unit is not free standing
Open in a new tab

Note: TJC = The Joint Commission

3.4. Statistical Analysis

A multiple imputation procedure was used to fill in the missing values as data were assumed to be missing at random (Rubin, 1987). Each missing value was replaced with five plausible values using the Markov Chain Monte Carlo method (Schaefer, 1997). The highest rate of missing data for any variable in the sample was approximately 8%. Five imputed datasets were developed, merged, and analyzed using STATA/SE (Version 10) ICE and MIM commands.

STATA/SE Version 10 was also used to conduct multivariate regression analysis relying on a hierarchical and cumulative approach. Because the conceptual framework describes a hierarchical process, the unique explained variance in the outcome by each independent variable was identified and compared across three consecutive statistical models. In other words, the first regression model identified the R-squared estimate of funding and regulation and degree of adoption. The second model included the indicator of professionalism, while the third cumulative hierarchical model included the indicator of managers’ cultural sensitivity. The R-squared estimate for each cumulative model was computed to examine the contribution of each concept (regulation, professionalism, and cultural sensitivity) to the degree of adoption, and to assess the necessary and sufficient condition proposed in Hypothesis 3.

4. Results

Findings offer partial support for Hypothesis 1—OSAT programs with a higher presence of regulation and public funding will report a higher degree of adoption of culturally and linguistically competent practices. Results for Model 1 in Table 2 show statistically significant positive relationships between the degree of adoption of linguistic and cultural competence and percentage of public revenue (p < .01), funding targeted to serve minorities (p < .001), and possession of a city license (p < .001). Yet state-licensed and TJC-certified programs were no more likely than unlicensed or noncertified programs to adopt a higher degree of these practices.

Table 2.

Impact of regulation, professionalism, and cultural sensitivity on degree of adoption

Degree of adoption of culturally and linguistically competent practices
Model 1
β (SE)		 Model 2
β (SE)		 Model 3
β (SE)
Independent variables
% public revenue 3.49 (1.24)** 3.36 (1.22)** 3.11 (1.22)*
Revenue for minority services 5.00 (1.43)** 4.93 (1.47)** 4.94 (1.50)**
State license −1.09 (1.57) −0.82 (1.50) −0.70 (1.45)
City license 4.86 (1.02)*** 4.63 (0.98)*** 4.40 (0.98)***
Accreditation (TJC) 1.25 (1.35) 1.53 (1.36) 1.66 (1.36)
Staff with graduate degree -- −0.05 (0.01)*** −0.05 (0.01)***
Manager’s cultural sensitivity -- 0.06 (0.02)**
Control variables
Client racial/ethnic & gender diversity
 High, Latinoa 7.48 (1.27)*** 7.10 (1.25)*** 7.40 (1.26)***
 Medium, Latinoa 0.76 (0.92) 1.07 (0.92) 0.94 (0.92)
 High, African Americanb 4.87 (0.98)*** 4.79 (0.97)*** 4.65 (0.97)***
 Low, African Americanb 0.71 (0.99) 0.87 (0.98) 0.79 (0.97)
Unit structure
 Unit size (number of clients) 0.39 (0.41) 0.47 (0.40) 0.50 (0.40)
 Staff resources 4.10 (3.55) 3.48 (3.47) 3.47 (3.47)
 Service comprehensiveness 0.23 (0.06)*** 0.24 (0.06)*** 0.20 (0.06)**
 Methadone provision 1.85 (1.08) 1.07 (1.07) 1.33 (1.06)
 Urban setting −2.12 (0.88)** −1.84 (0.87)* −1.5051
Ownership
 For-profitc −1.09 (1.74) −0.96 (1.72) −0.99 (1.70)
 Nonprofitc 0.74 (0.93) 0.44 (0.92) 0.46 (0.92)
Affiliation
 Hospitald −0.22 (1.45) −0.22 (1.46) −0.49 (1.47)
 Mental health facilityd 0.24 (0.96) 0.63 (0.96) 0.43 (0.96)
Constant 33.39 (2.22)*** 34.94 (2.24)*** 32.12 (2.34)***
R-Square 0.287 0.303 0.314
Observation 618 618 618
Open in a new tab

Note: Nonstandardized parameter estimates, with standard errors in parentheses from two-tailed test.

TJC = The Joint Commission

a

Units with low percentage (< 5%) of Latino clients is the referent.

b

Units with low percentage (< 10%) of African American clients is the referent.

c

Public is the referent.

d

Free-standing unit is the referent.

*

p < .05

**

p < .01

***

p < .001

Hypothesis 2, which posits that OSAT programs with higher professionalism will exhibit a higher degree of adoption of culturally and linguistically competent practices, was not supported. While Model 2 presented in Table 2 shows an R-squared increase of 1.6% in the predicted variance of degree of adoption, the relationship between the percentage of graduate professionals and the degree of adoption of these practices was inversely related (p < .001).

Findings offer partial support for Hypothesis 3. This hypothesis posited that professionalism and manager’s cultural sensitivity will contribute above and beyond the main effect of funding and regulation to the degree of adoption of culturally and linguistically competent practices in OSAT programs. The hierarchical approach presented in Table 2 shows three models. Model 1 includes the control variables and the five indicators of public funding and regulation. This model reported a total R-squared of .287, of which .12 was explained by the five indicators of funding and regulation. In Model 2, the addition of professionalism was associated with an increase in R-squared of .016. Finally, Model 3 included managers’ cultural sensitivity, which increased R-squared by .011. Although limited, professionalism and cultural sensitivity explained unique variance above and beyond the main effect of funding and regulation (.027). Yet professionalism hindered rather than promoted a higher degree of adoption of culturally and linguistically competent practices.

Regarding other variables, programs with the highest client diversity and service comprehensiveness achieved the highest degree of adoption, which is consistent with the emerging literature (Guerrero, 2010; Howard, 2003a). Programs serving a high proportion of African Americans (p < .001) and/or Latinos (p < .001) and offering a variety of services (p < .001) reported the most statistically significant relationships with degree of adoption. As expected, early adoption of higher degree of these practices is partially explained by clients’ racial/ethnic diversity representation and program resources.

5. Discussion

Findings suggest that the early development of a culturally and linguistically responsive system in the United States requires public resources and local regulation to increase program capacity. Consistent with findings of several studies, this analysis stresses the importance of public and targeted funding, as well as local licensing, as enabling factors for the provision of responsive services in OSAT programs (D’Aunno, 2006).

In contrast, programs with more graduate professionals, whose standards and ethics demand tailored services for racial and ethnic minorities, reported the lowest degree of adoption. In 1995, programs with a high number of graduate treatment professionals had mainly Caucasian staff (more than 75%), potentially limiting the capacity to provide bilingual and bicultural services. It should be noted, however, that providers’ commitment to adoption of new practices may go beyond external expectations and graduate training and include providers’ favorable view of and conviction about the practices’ effectiveness (Aarons & Palinkas, 2007; D’Aunno, Sutton, & Price, 1991). This is evident in the strong relationship found between managers’ cultural sensitivity and degree of adoption of culturally and linguistically competent practices.

5.1. Study Limitations

This study has some limitations, mainly associated with the methodology and nature of the data analyzed, that restricted the interpretability of findings. This study attempted to address issues related to different sources of bias. Managers’ social desirability can compromise the validity of responses. To reduce the effect of inaccurate responses, survey administrators corroborated responses between supervisors and directors (Adams & Herringa, 2001). Another source of bias is associated with common methods variance, which is present when data collection relies on similar methods or scales to collect data (Doty & Glick, 1998). This issue was addressed by using data from both directors and supervisors, and developing the composite outcome measure of degree of adoption. Still, caution is advised when interpreting results from cross-sectional data analysis, particularly in terms of issues related to reverse causality. It is conceivable that programs integrated many culturally responsive practices first and then sought supportive public funding and licenses or hired culturally responsive managers. This baseline study sought to reduce the potential for reverse causality by analyzing data from the beginning of the cultural competence movement.

5.2. Lessons Learned

Overall, these findings have important implications for future research on cultural competence, and for behavioral health administration policy that seeks to improve the quality of services for members of racial and ethnic minorities. Based on this baseline analysis of the early adoption of new practices in the nation’s substance abuse treatment system, future research on cultural competence would benefit from using a similar comprehensive measure to examine system capacity to develop a culturally and linguistically competent system of care. As the field of cultural competence has shifted the emphasis from enhancement of individual counselors’ skills to organizational policy and processes of care, it is crucial to develop refined measures of staff’s racial/ethnic diversity representation, cross-cultural training, and language proficiency to develop an evidentiary base for the impact of cultural competence on treatment outcomes.

Behavioral health care policy should consider the impact of the current racial homogeneity of providers and their development training needs. In OSAT, 85% of counselors are Caucasian and more than half of the client population belongs to an ethnic minority group (Mulvey, Hubbard, & Hayashi, 2003). Findings from this baseline study support current regulatory efforts to diversify and train the behavioral health workforce to increase the relevance and quality of services for cultural minorities.

As a nascent field, research on cultural competence is gradually maturing its conceptualization and measurement to become highly relevant to treatment outcomes (Vega, 2005). At this stage, the impetus to fully implement cultural competence may be viewed as based solely on the passion, need for legitimacy, and ideology of a group of providers, instead of common sense and evidence (Weinrach & Thomas, 1998). But robust evidence requires investment and refinement of outcome measurements. The current federal initiatives from the Patient Protection and Affordable Care Act will provide substantial incentives and regulation to increase workforce diversity, cross-cultural training, and cultural competence education among health care providers. This is a unique opportunity to develop policy with measurable outcomes and adequate monitoring of compliance to effectively disseminate evidence-based, culturally responsive practices and ensure positive treatment outcomes for cultural minorities (NCCC, 2006; Stork et al., 2001; Vega, 2005). It is only through effective collaboration between funders, regulators, and providers that culturally responsive systems of care can be built to ultimately reduce the current health disparities among ethnic minorities.

Highlights.

I examined the early organizational adoption of linguistic and culturally responsive practices. Regulation and culturally sensitive managers were associated with the highest degree of adoption. The lowest degree of adoption was observed in programs with more professionals. These baseline findings are discussed for future research and health care policy evaluation.

Acknowledgments

This research was supported by a predoctoral fellowship grant (1F31DA02456401, National Institute of Drug Abuse). Special thanks to Jeanne C. Marsh, Susan Lambert, Harold A. Pollack, and Bill Vega for their valuable feedback. Aspects of the analysis were presented at the Addiction Health Services Research meeting in San Francisco, CA, in October 2009.

Biography

Erick G. Guerrero is an Assistant Professor at the University of Southern California School of Social Work. His teaching interests include organizational change, managerial capacity, leadership, and multilevel research methods. His research interests include the organization, structure, and effectiveness of behavioral health services for racial and ethnic minorities, and the implementation of evidence-based linguistic and culturally responsive practices.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  1. Aarons GA, Palinkas LA. Implementation of evidence-based practice in child welfare: Service provider perspectives. Administration and Policy in Mental Health & Mental Health Services Research. 2007;34(4):411–419. doi: 10.1007/s10488-007-0121-3. [DOI] [PubMed] [Google Scholar]
  2. Adams TK, Herringa SG. Outpatient Substance Abuse Treatment Surveys (OSATSS): Technical Documentation for OSATSS-5, 1999–2000. Ann Arbor, MI: Survey Design and Analysis Unit, Survey Research Center, Institute for Social Research, University of Michigan; 2001. [Google Scholar]
  3. Agency for Healthcare Research and Quality. Ensuring cultural competence across care settings. Online event presented on March. 2010;18:2010. Retrieved from http://www.innovations.ahrq.gov/webevents/index.aspx?id=11.
  4. Andrulis DP, Siddiqui NJ, Purtle JP, Duchon L. Patient Protection and Affordable Care Act of 2010: Advancing health equity for racially and ethnically diverse populations. Washington, DC: Joint Center for Political and Economic Studies; 2010. Retrieved from http://www.jointcenter.org/hpi/sites/all/files/PatientProtection_PREP_0.pdf. [Google Scholar]
  5. Betancourt JR. Cultural competence—marginal or mainstream movement? New England Journal of Medicine. 2004;351(10):953–955. doi: 10.1056/NEJMp048033. [DOI] [PubMed] [Google Scholar]
  6. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O., II Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports. 2003;118(4):293–302. doi: 10.1016/S0033-3549(04)50253-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review. 2000;57(Suppl 1):181–217. doi: 10.1177/107755800773743655. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Campbell CI, Alexander JA. Culturally competent treatment practices and ancillary service use in outpatient substance abuse treatment. Journal of Substance Abuse Treatment. 2002;22(3):109–119. doi: 10.1016/S0740-5472(02)00221-0. [DOI] [PubMed] [Google Scholar]
  9. Campbell CI, Alexander JA. Health services for women in outpatient substance abuse treatment. Health Services Research. 2005;40(3):781–810. doi: 10.1111/j.1475-6773.2005.00385.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Campbell CI, Alexander JA, Lemak CH. Organizational determinants of outpatient substance abuse treatment duration in women. Journal of Substance Abuse Treatment. 2009;37(1):64–72. doi: 10.1016/j.jsat.2008.09.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Center for Substance Abuse Treatment. Technical Assistance Publication (TAP) Series 31, DHHS Publication No. (SMA) 09-4377. Rockville, MD: Substance Abuse and Mental Health Administration; 2009a. Implementing change in substance abuse treatment programs. Retrieved from http://kap.samhsa.gov/products/manuals/pdfs/TAP31.pdf. [Google Scholar]
  12. Center for Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 52, DHHS Publication No. (SMA) 09-4435. Rockville, MD: Substance Abuse and Mental Health Administration; 2009b. Clinical supervision and professional development of the substance abuse counselor. Retrieved from http://kap.samhsa.gov/products/manuals/tips/pdf/TIP52.pdf. [PubMed] [Google Scholar]
  13. Center for Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series 46, DHHS Publication No. (SMA) 06-4151. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2006. Substance abuse: Administrative issues in outpatient treatment. [PubMed] [Google Scholar]
  14. D’Aunno TA. The role of organization and management in substance abuse treatment: Review and roadmap. Journal of Substance Abuse Treatment. 2006;31(3):221–233. doi: 10.1016/j.jsat.2006.06.016. [DOI] [PubMed] [Google Scholar]
  15. D’Aunno TA, Pollack HA. Changes in methadone treatment practices: Results from a national panel study, 1988–2000. Journal of the American Medical Association. 2002;288(7):850–856. doi: 10.1001/jama.288.7.850. [DOI] [PubMed] [Google Scholar]
  16. D’Aunno TA, Sutton RI, Price RH. Isomorphism and external support in conflicting institutional environments: A study of drug abuse treatment units. Academy of Management Journal. 1991;34(3):636–661. [PubMed] [Google Scholar]
  17. DiMaggio PJ, Powell WW. The iron cage revisited: Institutional isomorphism and collective rationality in organizational fields. American Sociological Review. 1983;48(2):147–160. [Google Scholar]
  18. Doty DH, Glick WH. Common methods bias: Does common methods variance really bias results? Organizational Research Methods. 1998;1(4):374–406. doi: 10.1177/109442819814002. [DOI] [Google Scholar]
  19. Durkin EM. An organizational analysis of psychosocial and medical services in outpatient drug abuse treatment programs. Social Service Review. 2002;76(3):406–429. doi: 10.1086/341182. [DOI] [Google Scholar]
  20. Fischer TL, Burnet DL, Huang ES, Chin MH, Cagney KA. Cultural leverage: Interventions using culture to narrow racial disparities in health care. Medical Care Research and Review. 2007;64(5):243s–282s. doi: 10.1177/1077558707305414. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Friedmann PD, D’Aunno TA, Jin L, Alexander JA. Medical and psychosocial services in drug abuse treatment: Do stronger linkages promote client utilization? Health Services Research. 2000;35(2):443–465. [PMC free article] [PubMed] [Google Scholar]
  22. Guerrero EG. Managerial capacity and adoption of culturally competent practices in outpatient substance abuse treatment. Journal of Substance Abuse Treatment. 2010;39(4):329–339. doi: 10.1016/j.jsat.2010.07.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Guerrero EG, Andrews C. Cultural competence in outpatient substance abuse treatment: Measurement and relationship with wait time and retention. Drug and Alcohol Dependence. doi: 10.1016/j.drugalcdep.2011.05.020. (In press) [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hasenfeld Y. Human service organizations. Englewood Cliffs, NJ: Prentice Hall; 1983. [Google Scholar]
  25. Henderson CE, Taxman FS, Young DW. A Rasch model analysis of evidence-based treatment practices used in the criminal justice system. Drug and Alcohol Dependence. 2008;93(1–2):163–175. doi: 10.1016/j.drugalcdep.2007.09.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Howard DL. Culturally competent treatment of African American clients among a national sample of outpatient substance abuse treatment units. Journal of Substance Abuse Treatment. 2003a;24(2):89–102. doi: 10.1016/S0740-5472(02)00348-3. [DOI] [PubMed] [Google Scholar]
  27. Howard DL. Are the treatment goals of culturally competent outpatient substance abuse treatment units congruent with their client profile? Journal of Substance Abuse Treatment. 2003b;24(2):103–113. doi: 10.1016/S0740-5472(02)00349-5. [DOI] [PubMed] [Google Scholar]
  28. Klein KJ, Sorra JS. The challenge of innovation implementation. Academy of Management Review. 1996;21(4):1055–1080. [Google Scholar]
  29. Knudsen HK, Roman PM. Modeling the use of innovations in private treatment organizations: The role of absorptive capacity. Journal of Substance Abuse Treatment. 2004;26(1):51–59. doi: 10.1016/S0740-5472(03)00158-2. [DOI] [PubMed] [Google Scholar]
  30. Marsh JC, Cao D, D’Aunno TA. Gender differences in the impact of comprehensive services in substance abuse treatment. Journal of Substance Abuse Treatment. 2004;27(4):289–300. doi: 10.1016/j.jsat.2004.08.004. [DOI] [PubMed] [Google Scholar]
  31. Miller WR, Sorensen JL, Selzer JA, Brigham GS. Disseminating evidence-based practices in substance abuse treatment: A review with suggestions. Journal of Substance Abuse Treatment. 2006;31(1):25–39. doi: 10.1016/j.jsat.2006.03.005. [DOI] [PubMed] [Google Scholar]
  32. Mulvey KP, Hubbard S, Hayashi S. A national study of the substance abuse treatment workforce. Journal of Substance Abuse Treatment. 2003;24(1):51–57. doi: 10.1016/S0740-5472(02)00322-7. [DOI] [PubMed] [Google Scholar]
  33. National Center for Cultural Competence. Definition of objectives for organizational cultural competence and service efficacy. Washington, DC: Center for Child and Human Development, Georgetown University; 2010. Retrieved from http://nccc.georgetown.edu. [Google Scholar]
  34. National Center for Cultural Competence. Linguistic competence in primary health care delivery systems: Implications for policy makers. Washington, DC: Center for Child and Human Development, Georgetown University; 2006. Retrieved from http://www11.georgetown.edu/research/gucchd/nccc/documents/Policy_Brief_2_2003.pdf. [Google Scholar]
  35. Office of Applied Studies. The DASIS Report: Hispanic female admissions in substance abuse treatment: 2005. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007. Retrieved from http://oas.samhsa.gov/2k7/latinaTX/latinas.pdf. [Google Scholar]
  36. Office of Applied Studies. DSDUH Series H-34, DHHS Publication No. (SMA) 08-4343. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2009. The NSDUH Report: Substance use treatment need and receipt among Hispanics. Retrieved from http://oas.samhsa.gov/2k9/164/HispanicsHTML.pdf. [Google Scholar]
  37. Oliver C. Strategic responses to institutional processes. Academy of Management Review. 1991;16(1):145–179. [Google Scholar]
  38. Peyrot M. Institutional and organizational dynamics in community-based drug abuse treatment. Social Problems. 1991;38(1):20–33. [Google Scholar]
  39. Pollack HA, D’Aunno TA, Lamar B. Outpatient substance abuse treatment and HIV prevention: An update. Journal of Substance Abuse Treatment. 2006;30(1):39–47. doi: 10.1016/j.jsat.2005.09.002. [DOI] [PubMed] [Google Scholar]
  40. Roman PM, Ducharme LJ, Knudsen HK. Patterns of organization and management in private and public substance abuse treatment programs. Journal of Substance Abuse Treatment. 2006;31(3):235–243. doi: 10.1016/j.jsat.2006.06.017. [DOI] [PubMed] [Google Scholar]
  41. Rubin DB. Multiple imputation for non-response in surveys. New York, NY: John Wiley & Sons; 1987. [Google Scholar]
  42. Schafer JL. Analysis of incomplete multivariate data. New York, NY: Chapman and Hall; 1997. [Google Scholar]
  43. Scott WR. Institutions and organizations. 2. Thousand Oaks, CA: Sage; 2001. [Google Scholar]
  44. Scott WR, Ruef M, Mendel PJ, Caronna CA. Institutional change and healthcare organizations. Chicago, IL: University of Chicago Press; 2000. Institutional environments and organizational legitimacy; pp. 236–264. [Google Scholar]
  45. Simpson DD, Flynn PM. Moving innovations into treatment: A stage-based approach to program change. Journal of Substance Abuse Treatment. 2007;33(2):111–120. doi: 10.1016/j.jsat.2006.12.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Stork E, Scholle S, Greeno C, Copeland VC, Kelleher K. Monitoring and enforcing cultural competence in Medicaid managed behavioral health care. Mental Health Service Research. 2001;3(3):169–177. doi: 10.1023/A:1011575632212. [DOI] [PubMed] [Google Scholar]
  47. Thornton PH, Ocasio W. Institutional logics. In: Greenwood R, Oliver C, Sahlin K, Suddaby R, editors. The SAGE handbook of organizational institutionalism. Thousand Oaks, CA: Sage; 2008. pp. 99–129. [Google Scholar]
  48. Ulmer C, McFadden B, Nerenz DR, editors. Report of Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement, Board on Health Care Services, Institute of Medicine. Washington, DC: National Academies Press; 2009. Race, ethnicity, and language data: Standardization for health care quality improvement. [PubMed] [Google Scholar]
  49. Vega WA. Higher stakes ahead for cultural competence. General Hospital Psychiatry. 2005;27(6):446–450. doi: 10.1016/j.genhosppsych.2005.06.007. [DOI] [PubMed] [Google Scholar]
  50. Weinrach SG, Thomas KR. Diversity-sensitive counseling today: A postmodern clash of values. Journal of Counseling and Development. 1998;76(2):115–122. [Google Scholar]
  51. Wells K, Klap R, Koike A, Sherbourne C. Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. American Journal of Psychiatry. 2001;158(12):2027–2032. doi: 10.1176/appi.ajp.158.12.2027. [DOI] [PubMed] [Google Scholar]
  52. Wells R, Lemak CH, D’Aunno TA. Insights from a national survey into why substance abuse treatment units add prevention and outreach services. Substance Abuse Treatment, Prevention, and Policy. 2006;1:21. doi: 10.1186/1747-597X-1-21. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Wilson-Stronks A, Galvez E. Exploring cultural and linguistic services in the nation’s hospitals: A report of findings. Oakbrook Terrace, IL: The Joint Commission; 2007. [Google Scholar]
  54. Wright BD, Masters GN. Rating scale analysis: Rasch measurement. Chicago, IL: MESA Press; 1982. [Google Scholar]
  55. Zane N, Gordon CNH, Sue S, Young K, Nunez J. Research on psychotherapy with culturally diverse populations. In: Lambert M, editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. Vol. 5. New York, NY: John Wiley & Sons; 2004. pp. 767–804. [Google Scholar]

RESOURCES