Form 1 Checklist

Health Resources and Services Administration
Office of Federal Assistance Management
Division of Grants Policy
Grants Policy Operations Memo (GPOM)
GPOM-2011-01

June 22, 2011

CULTURAL AND LINGUISTIC COMPETENCE AND HEALTH LITERACY
In order to fully integrate cultural and linguistic competence and health literacy
factors into HRSA funding opportunity announcements (FOA), new template
language has been developed and a performance measure recommended. This
language should receive careful consideration whenever program FOAs are being
developed.

A. BACKGROUND AND DEFINITIONS
The Health Resources and Services Administration (HRSA) vision is “Healthy
Communities, Healthy People.” In addition, the HRSA mission statement is “To
improve health and achieve health equity through access to quality services, a
skilled health workforce and innovative programs.” This is the framework that
supports a health care system that assures access to comprehensive, culturally
competent, quality care.
‘Culture’ refers to integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and institutions of
racial, ethnic, religious, or social groups. ‘Competence’ implies having the capacity
to function effectively as an individual and an organization within the context of the
cultural beliefs, behaviors, and needs presented by consumers and their
communities. (Adapted from Cross, et. al, 1989; cited from DHHS Office of Minority
Health) For more information go to
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&lvlID=3.
HRSA programs serve culturally and linguistically diverse communities and multiple
cultures. Although race and ethnicity are often thought to be dominant elements of
culture, HRSA funded programs embrace a broader definition to include language,
gender, socio-economic status, sexual orientation and gender identity, physical and
mental capacity, age, religion, housing status, and regional differences.
Organizational behaviors, practices, attitudes, and policies across all HRSAsupported entities respect and respond to the cultural diversity of communities,
clients and students served.
HRSA defines cultural competence as a set of congruent behaviors, attitudes, and
policies integrated in a system, agency, or among professionals to enable that
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system, agency, or those professionals to work effectively in cross-cultural and
linguistically diverse situations. Healthcare providers, as well as institutions that
train healthcare workers, funded through HRSA grants and cooperative agreements
should be aware of cross-cultural and language-appropriate communications, as
well as general health literacy issues. HRSA continues to support and promote a
unified health communication perspective that addresses cultural competency,
limited English proficiency, and health literacy for HRSA-funded providers and staff
to deliver quality health care to diverse populations
Linguistic competence is the capacity of an organization and its personnel to
communicate effectively, and convey information in a manner that is easily
understood by diverse audiences including persons of limited English proficiency,
those who have low literacy skills or are not literate, and individuals with disabilities.
Linguistic competency requires organizational and provider capacity to respond
effectively to the health literacy needs of populations served. The organization must
have policies, structures, practices, procedures, and dedicated resources to support
this capacity. 1
Cultural and linguistic competency is a process that occurs along a developmental
continuum. A culturally and linguistically competent program is characterized by
elements including the following: written strategies for advancing cultural
competence; cultural and linguistic competency policies and practices; cultural and
linguistic competence knowledge and skills building efforts; research data on
populations served according to racial, ethnic, and linguistic groupings; participation
of community and family members of diverse cultures in all aspects of the program;
faculty and other instructors are racially and ethnically diverse; faculty and staff
participate in professional development activities related to cultural and linguistic
competence; and periodic assessment of trainees’ progress in developing cultural
and linguistic competence.
The Patient Protection and Affordable Care Act defines health literacy as “the
degree to which an individual has the capacity to obtain, communicate, process,
and understand health information and services in order to make appropriate health
decisions.” (Title V—Health Care Workforce, Subtitle A—Purpose and Definitions.)
For additional online resources on health literacy please see the following:
•

•
•

Cultural competency and health literacy tools, resources and definitions are
available online at http://www.hrsa.gov/culturalcompetence and
http://www.hrsa.gov/healthliteracy
Health Literacy Universal Precautions Toolkit Agency for Health Care Quality
and Research
Simply Put: A Guide for Creating Easy-to-Understand Materials

1

Goode, T. and W. Jones, 2004. National Center for Cultural Competence;
http://www.nccccurricula.info/linguisticcompetence.html

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•
•
•
•

Clear Communication: An NIH Health Literacy Initiative National Institutes of
Health
Plain Language.gov -- Improving Communication from the Federal
Government to the Public
Health Literacy Online Guide U.S. Department of Health and Human
Services
Health Literacy for Public Health Professionals Centers for Disease Control
and Prevention

B. POLICY
HRSA Bureaus/Offices currently include special language regarding cultural
competence, limited English proficiency and health literacy in many FOAs, as
appropriate. However, broader application of these principles in future FOAs,
particularly for health services, education, and training programs is recommended.
To that end, the Office of Health Equity, in consultation with the HRSA Culture,
Language and Health Literacy Committee, developed template language for use in
FOAs.
The suggested language contained in Section C below may vary by Bureau/Office
and by grant and cooperative agreement program; therefore, it is not appropriate to
require that the language be included verbatim in all FOAs. However, it is expected
that all Bureaus/Offices will review the language carefully for items that may be
appropriate for inclusion in individual FOAs. It is recommended that applicants
address culture, language and health literacy in response to requirements
throughout the application, and subsequently reflected in the review criteria, as
appropriate.
HRSA Bureaus/Offices are also encouraged to incorporate the Performance
Measure and Data Collection Checklist (or a modified version of it) contained in
Section D in their FOAs either as a stand-alone or integrated measure.

C. CULTURAL AND LINGUISTIC LANGUAGE FOR FOA TEMPLATES
HRSA is committed to ensuring access to quality health care for all. Quality care
means access to services, information and materials delivered by competent
providers in a manner that factors in the language needs, health literacy, cultural
richness, and diversity of the populations served. Quality also means that, where
appropriate, data collection instruments used should adhere to culturally competent
and linguistically appropriate norms. For additional information and guidance, refer
to the National Standards for Culturally and Linguistically Appropriate Services in
Health Care published by the U.S. Department of Health and Human Services
(http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15). As
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appropriate, bureaus and offices should include the following language in the
subsequent sections of their funding opportunity announcements:
•

In Section IV. v. Budget Justification within the cost category of “Other”:
Applicants may include the cost of access accommodations as part of their
project’s budget, including sign interpreters, plain language and health
literate print materials in alternate formats (including Braille, large print, etc.);
and cultural/linguistic competence modifications such as use of cultural
brokers, translation or interpretation services at meetings, clinical
encounters, and conferences, etc.

•

In Section IV. vi. Staffing Plan and Personnel Requirements:
When applicable, biographical sketches should include training, language
fluency and experience working with the cultural and linguistically diverse
populations that are served by their programs.

•

In Section IV. x. Program Narrative under “Needs Assessment”:
Include socio-cultural determinants of health and health disparities impacting
the population or communities served and unmet.

•

In Section IV. x. Program Narrative under “Methodology”:
As appropriate, include development of effective tools and strategies for
ongoing staff training, outreach, collaborations, clear communication, and
information sharing/dissemination with efforts to involve patients, families and
communities of culturally, linguistically, socio-economically and
geographically diverse backgrounds, if applicable.

•

In Section IV. x. Program Narrative under “Work Plan”:
As appropriate, identify meaningful support and collaboration with key
stakeholders in planning, designing and implementing all activities, including
development of the application and, further, the extent to which these
contributors reflect the cultural, racial, linguistic and geographic diversity of
the populations and communities served.

•

In Section IV. x. Program Narrative under “Evaluation and Technical Support
Capacity”:
As appropriate, describe the data collection strategy to collect, analyze and
track data to measure process and impact/outcomes, with different cultural
groups (e.g., race, ethnicity, language) and explain how the data will be used
to inform program development and service delivery.

•

In Section IV. x. Program Narrative under “Organizational Information”:
Provide information on the program’s resources and capabilities to support
provision of culturally and linguistically competent and health literate
services. Describe how the unique needs of target populations of the
communities served are routinely assessed and improved.

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As appropriate, additional application requirements could include the following:
•

In Section IV. x. Program Narrative under “Methodology”:
Identify programs that (1) improve medication adherence of patients, and (2)
improve patient understanding regarding health conditions and (3) improve
the ability of the patient to manage their condition.
Summarize specific training, and/or learning experiences to foster knowledge
and appreciation of how culture and language influence health literacy,
patient safety, and access to high quality, effective, and predictably safe
healthcare services and provide a training plan to increase self-awareness of
cultural, language and health literacy issues that may engage individuals,
families, and communities from diverse backgrounds in self-managing their
health care.

•

In Section IV. x. Program Narrative under “Organizational Information”:
Describe the program’s or institution’s strategic plan, policies, and initiatives
that demonstrate a commitment in providing competent health care and
developing health literate, culturally and linguistically competent health care
providers, faculty, staff, and program participants. This includes participation
in, and support of programs that focus on: 1) familiarity with the culture and
literacy level of the particular target groups; 2) cross-cultural health
communication approaches as strategies to educate health care providers,
who serve diverse patients, families, and communities.
Describe the program’s or institution’s past performance in recruiting and
retaining health care providers, faculty, staff and students who have
demonstrated experience serving the particular ethno-cultural and linguistic
populations residing in the proposed service area.

D. CULTURAL AND LINGUISTIC COMPETENCE AND HEALTH LITERACY
PERFORMANCE MEASURES
Performance measures have been helpful for HRSA project officers to assess each
grantee. In addition, the tool that follows has proven useful for grantees’ selfassessment. This tool can also offer insights into technical assistance challenges
and opportunities. HRSA Bureaus/Offices are strongly encouraged to incorporate
this performance measure or a modified version of this measure into their funding
opportunity announcements either as a stand-alone or integrated measure.
Using a scale of 0-3, the grantee may use the Data Collection Checklist to assess if
the following cultural/linguistic competence and health literacy elements have been
incorporated into their policies, guidelines, contracts and training. Each HRSA
program may add data sources and year of data used for scoring to provide a
rationale for determining a score, and/or applicability of elements to a specific
program.
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The following is a modified version of a performance measure that has been used in
the Maternal and Child Health Bureau. 2
GOAL

To increase the number of HRSA-funded programs that have
integrated cultural and linguistic competence and health
literacy into their policies, guidelines, contracts and training.

MEASURE

The degree to which HRSA-funded programs have
incorporated cultural and linguistic competence and health
literacy elements into their policies, guidelines, contracts and
training.

DATA
The attached data collection form is to be completed by
SOURCE(S) AND grantees. Currently, there are no existing national data
ISSUES
sources to measure the extent to which HRSA supported
programs have incorporated cultural and linguistic
competency and health literacy elements into their policies,
guidelines, contracts and training.
SIGNIFICANCE

2

Over the last decade, researchers and policymakers have
emphasized the central influence of cultural values and
cultural/linguistic and health literacy barriers: health seeking
behavior, access to care, and racial and ethnic disparities.
In accordance with these concerns, cultural competence
objectives have been: incorporated into the HRSA strategic
plan, funding opportunity announcements, and, wherever
appropriate, reporting requirements.

This checklist is provided for informational purposes only.

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DATA COLLECTION CHECKLIST
Using a scale of 0-3, please rate the degree to which your grant or cooperative
agreement funded program has incorporated the following cultural/linguistic
competency and health literacy elements into your policies, guidelines, contracts
and training.
Please use the space provided for notes to describe activities related to each
element, detail data sources and year of data used to develop score, clarify any
reasons for score, and/or explain the applicability of elements to program.

0 1 2 3

Element
1. Strategies for advancing cultural and linguistic competency and health
literacy are integrated into your program’s written plan(s) (e.g., grant
application, recruiting plan, placement procedures, monitoring and
evaluation plan, human resources, formal agreements, etc.).
2. There are structures, resources, and practices within your program to
advance and sustain cultural and linguistic competency and health
literacy.
3. Cultural and linguistic competency and health literacy knowledge and
skills building are included in training aspects of your program.
4. Research or program information gathering includes the collection and
analysis of granular data on populations served according to racial,
ethnic, linguistic and health literacy groupings, where appropriate.
5. Community/family members/students from diverse cultural groups are
partners in planning your program.
6. Community/family members/students from diverse cultural groups are
partners in the delivery of your program.
7. Community/family members/students from diverse cultural groups are
partners in evaluation of your educational program.
8. Staff and faculty reflect cultural and linguistic diversity of the significant
populations served.
9. Staff and faculty participate in professional development activities to
promote their cultural, linguistic and health literacy (clear language)
competence.
10. A process is in place to assess the progress of your program
participants/students in developing cultural, linguistic and health literacy
competence.

0 = Not Met
1 = Partially Met
2 = Mostly Met
3 = Completely Met

Total the numbers in the boxes (possible 0-30 score) __________
NOTES/COMMENTS:

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