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Providing Care to Diverse Populations

State Strategies for Promoting Cultural Competency in Health Systems

A Workshop for Senior State Health Officials

The Agency for Health Care Policy and Research (AHCPR) sponsored this workshop in order to provide a forum for State officials to examine the issues related to the development of culturally competent health care systems. It was held in Charleston, South Carolina, June 9-11, 1999.

About the Workshop Sponsor.


Although the population of the United States has always included a rich mix of individuals with different racial, ethnic, and cultural backgrounds, today it is becoming even more dynamic. The U.S. Census Bureau projects that the proportion of the overall population considered to be "minority" (those persons who are not white and of non-Hispanic origin) will increase from 26.4 percent in 1995 to 47.2 percent in 2050. By the year 2030, minority children will account for more than one-half of the Nations's population under age 18. This rapid change in population patterns necessitates a serious evaluation of how minority populations access and receive quality health care.

Research findings indicate that significant disparities in health status exist across racial and ethnic groups, with most health-status indicators being far worse for minority populations than for white non-Hispanic populations. For example, death rates from heart disease and cancer are significantly higher for black persons than for non-Hispanic white persons. Infant mortality rates are also alarmingly high for most minority populations.

Many of these disparities may be due, at least in part, to problems that racial and ethnic minorities may have in accessing and effectively utilizing the health care system. A solid and growing body of research shows differences in utilization levels across racial and ethnic groups and in the nature of the care that minority groups receive.

One example is a recently released study of referral patterns by primary care physicians that found, under similar circumstances, black persons and women would be referred for cardiac catheterization only 40 percent as often as white male patients.

These findings support the growing view that the health care system is not "culturally competent." It is neither adequately accessible nor responsive to the health needs of the country's increasingly diverse populations. In addition to the overarching equity concerns that issues of health care disparities raise, this situation is particularly disturbing because of concerns about unmet health needs of these groups, the effectiveness of the health care that they do receive, and the increased cost of treating persons with preventable conditions.

To promote the delivery of health care services that better address the needs of racial and ethnic minorities, it is increasingly important to improve the cultural competence of health care delivery systems and providers. There are, however, several significant challenges that public policymakers and program administrators face in trying to promote this objective.

First is the challenge of understanding what changes and approaches are successful in making our health care systems and providers more responsive and effective in meeting the needs of diverse populations.

Also, it is important not only to find out how to identify effective strategies, but also to determine how to implement these measures in a way that will result in lasting improvements in the behavior of health systems, service delivery organizations, and individual practitioners.

Once a successful approach is identified, the next significant challenge for State policymakers and program administrators is how to use the State's different roles to effect change. States are purchasers of care for diverse populations through Medicaid and other programs, are regulators, and influence the education and training of health professionals. In these roles, how can States design and implement successful and appropriate strategies that promote improved access to and provision of health care for diverse populations and increased capability of health professionals to serve these populations?


This two-½-day workshop was intended to help State officials address these challenges. The specific objectives of the workshop were to:

  • Present data and health services research findings that identify the relationships between health status disparities across racial and ethnic populations; differences in access, treatment patterns, and outcomes across these groups; and the aspects of health delivery systems and providers that relate to cultural competence.
  • Discuss practical, operational definitions of cultural competence and provide useful insights from "real world" examples of innovative approaches to promote cultural competence at the health plan, health system, and community level.
  • Identify a range of strategies that States can pursue to improve the effectiveness of health care organizations and providers in caring for diverse populations, as well as the issues, opportunities, and challenges associated with these approaches.
  • Examine the experiences of individual States implementing promising initiatives to promote cultural competence and highlight the rationale behind the selection of individual approaches, experiences to date, and valuable lessons learned.
  • Explore key data, assessment, and evaluation issues associated with cultural-competence initiatives.
  • Highlight opportunities for State officials to play leadership roles in working to improve the delivery of care to diverse populations.


Participants at this workshop were health officials representing a broad range of organizations including State legislatures, State Medicaid agencies, State departments of minority health and social services, governors' offices, insurance departments, and Federal and State health departments.

Workshop Sessions


The User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.

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