An organizational analysis of the adoption of cultural competence in outpatient substance abuse treatment

Cultural competence -- through which organizations recognize and are responsive to the needs of culturally diverse populations -- has become a common and widely supported approach to potentially decrease minorities' health disparities in substance abuse treatment. Significant support for this service delivery model stems from institutional actors (state and professional entities), who exert influence on outpatient substance abuse treatment (OSAT) organizations to offer legitimate practices. However, it is not known to what extent OSAT treatment units adopt culturally competent practices because of the external expectations of these institutional actors. Neo-institutional theory was used to examine to what extent external and internal organizational pressures play a role in the adoption of culturally competent practices in OSAT units.;I examined the National Drug Abuse Treatment Services Survey (NDATSS), a nationally representative sample of OSAT units in the U.S. I used item response theory (Rasch measurement model) to create an outcome measure representing 14 organizational practices considered culturally competent. This measure and single core practices, such as matching counselors and clients based on race/ethnicity or language and offering cross-cultural training for staff were used in cross-sectional and longitudinal statistical analyses. These analyses helped me assess the relationship between institutional arrangements (public funding, licensing, accreditation and professionalism), managerial beliefs and offering culturally competent practices in OSAT units. In addition, I employed structural equation modeling to explore the mediating role of managers' support for cultural competence in the relationship between OSAT units having institutional arrangements and offering culturally competent practices.;Results from item response analysis showed that empirically, cultural competence has become a legitimate service delivery model, which is represented by offering matching practices based on race/ethnicity and language, and training staff in cross-cultural issues. Offering single practices or reporting a high degree of adoption of all practices was most likely in treatment units supervised by managers who strongly believed in cultural competence, as well as in units with more dependence on institutional resources, primarily government funding and licensing regulation. In contrast, indicators of institutional professional norms associated with service quality (graduate professionals in the unit and professional accreditation (JCAHO)) inhibited rather than promoted the adoption of the service delivery logic of cultural competence. Finally, while both, managers' support for cultural competence, and units' regulative pressures (funding and licensing) were positively associated with offering culturally competent practices, managers' support for cultural competence did not mediate the relationship between regulative pressures and offering these practices. Overall, results suggest that managers face conflicting demands from external and internal entities and that these demands play separate roles in the adoption process of cultural competence in this organizational environment.;These findings are relevant for both organizational theory and health care management policy. Findings inform theory by stressing two avenues to enact organizational change - managers' commitment to a service delivery model and institutions' use of funding resources and regulation to influence adoption of a legitimate service logic. For policy, these findings help identify regulative mechanisms and organizational structures that may allow the state to ensure that OSAT units respond to the language and cultural service needs of Latino and African American clients in order to respond to improve their health outcomes.