In This Section


Cultural Competence Key Score in NAMI’s Grading the States 2009

Recovery for All
March 2009

for more extensive information about Grading the States 2009, find details about your state grade, and to access the full report.

Released in March, Grading the States 2009 examines the nation’s public mental health care system through a comprehensive, comparative state-by-state assessment. Though 14 states have improved grades since NAMI’s first Grading the States report in 2006, 12 states have slipped and the national average D grade has not budged. NAMI concludes, yet again, that mental healthcare in America is in crisis. Among the key findings of this report: states are not ensuring their service delivery is culturally competent.

State grades for 2009 are less than flattering: 6 Bs, 18 Cs, 21 Ds and 6 Fs* . Grades are based on 65 specific criteria of ideal state mental health services for adults with serious mental illness. Data on these criteria were scored and weighted to reflect NAMI’s judgment of each measure’s importance relative to an ideal mental health system. Scoring on cultural competence was one of the five highest weighted criteria of state grades, indicating that cultural competency is an essential element of a successful mental health system.

Summary of State-by-State Cultural Competence Ratings

"Mental health systems must be sensitive and responsive to people’s unique cultural circumstances, including race and ethnicity, national origin, ancestry, religion, age, gender, sexual orientation, physical disabilities, and specific family or community values and customs." 

-Grading the States 2009

Click here for more information on cultural competence.

  • Only five states—Arizona, California, Connecticut, Hawaii, and Massachusetts—received the highest possible cultural competence score (three out of three possible points). These states have exemplary cultural competence plans and activities, can provide significant evidence that they are implementing cultural competence initiatives, and demonstrate significant progress made in these initiatives.
  • Thirty-six state cultural competence scores are below average effort, reflecting only "partial effort" (one point) or "little to no effort" (zero points) to develop cultural competence. These states have either substandard development or progress made on cultural competence or disparities plans or no such plans developed.
  • Only 3 of the 10 states with the largest racial/ethnic minority populations (Hawaii, California, and Arizona) have made major inroads in becoming more culturally competent and improving for racial/ethnic communities. New Mexico, Texas, Mississippi, Maryland, Georgia, Nevada, and New York urgently need to improve their levels of cultural competence and mental health services to minority communities.

Methodology for Evaluation of Cultural Competence

The following definition of cultural competence was utilized in this evaluation:

Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations[1].

Several sources provided the data set for developing each state’s cultural competence score. In August 2008, NAMI surveyed state mental health agencies in preparation for Grading the States 2009. Data for the cultural competence score was collected from specific items of this survey, such as state Medicaid program reimbursement of language access services, promotion of cultural competency among providers (by regulation, training, and/or funding incentives), and collection of racial/ethnic population outcomes data on key state initiatives such as suicide prevention.

In addition to completing the 2008 survey, states were asked to provide supplemental information through both a comprehensive state plan or strategy to eliminate/reduce disparities in mental health for racial and ethnic minority communities and a comprehensive cultural competence plan as supplements to survey responses.

Cultural competence plans were further evaluated on the following specific areas:

  • Consumer, family, and community involvement in the planning process
  • Race/ethnicity-specific penetration and retention rates
  • Cultural competence standards and requirements for service contracts and quality management plans
  • Cultural competence training components for staff, contractors, and other stakeholders
  • Measurable cultural competence performance indicators, outcomes, and timetables
  • Language access components
  • Evidence of progress on this plan

Cultural competence scoring also reflected whether or not the state mental health authority employs a full-time cultural competence director or coordinator. This was determined through the Cultural and Linguistic Competence Coordinators’ Network for State, Territorial and Tribal Mental Health Services, led by NAMI and the Georgetown National Center on Cultural Competence

Conclusions on the Role of Cultural Competence in the Mental Health System

Grading the States 2009 identifies establishing cultural competence as one of “10 pillars of a high-quality state mental health system.” The report recognizes, in agreement with the New Freedom Commission[2], that providing culturally competent care is an effective way to reduce disparities in mental health treatment and outcomes. And though a number of state mental health systems have made great strides in increasing their cultural competence—using evidence-based practices to bring cultural awareness to their workforce training, service delivery, written materials, and other resources—overall, most states have a long way to go in order to provide quality mental health services for racial and ethnic minorities.

As the U.S. Census Bureau’s latest data projects, current racial/ethnic minority groups are to become a national majority by 2042[3]. State mental health systems must give significant attention and effort to address the existing disparities in care for these communities. States’ commitment to cultural competence and eliminating disparities can improve mental health care outcomes for diverse populations now and vastly improve the public systems’ ability to address rapidly expanding needs. 

* All 50 states and the District of Columbia were included in the state-by-state assessment.

[1] Cross, T., Bazron, B., Dennis, K. & Isaacs, M.  (1989)  Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.

[2] U.S. Census Bureau News (2008). An Older and More Diverse Nation by Midcentury. Retrieved November 14, 2008 from

[3] U.S. Department of Health and Human Services. (2003) New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. Retrieved November 14, 2008, from

Back to top