Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions

Is the Front Line Prepared for the Changing Faces of Patients? Predictors of Cross-Cultural Preparedness Among Clinical Nurses and Resident Physicians in Lausanne, Switzerland

PHENOMENON: Assuring quality medical care for all persons requires that healthcare providers understand how sociocultural factors affect a patient's health beliefs/behaviors. Switzerland's changing demographics highlight the importance of provider cross-cultural preparedness for all patients-especially those at risk for social/health precarity. We evaluated healthcare provider cross-cultural preparedness for commonly encountered vulnerable patient profiles.

APPROACH

A survey on cross-cultural care was mailed to Lausanne University hospital's "front-line healthcare providers": clinical nurses and resident physicians at our institution. Preparedness items asked "How prepared do you feel to care for … ?" (referring to example patient profiles) on an ascending 5-point Likert scale. We examined proportions of "4 - well/5 - very well prepared" and the mean composite score for preparedness. We used linear regression to examine the adjusted effect of demographics, work context, cultural-competence training, and cross-cultural care problem awareness, on preparedness.

FINDINGS

Of 885 questionnaires, 368 (41.2%) were returned: 124 (33.6%) physicians and 244 (66.4%) nurses. Mean preparedness composite was 3.30 (SD = 0.70), with the lowest proportion of healthcare providers feeling prepared for patients "whose religious beliefs affect treatment" (22%). After adjustment, working in a sensitized department (β = 0.21, p = .01), training on the history/culture of a specific group (β = 0.25, p = .03), and awareness regarding (a) a lack of practical experience caring for diverse populations (β = 0.25, p = .004) and (b) inadequate cross-cultural training (β = 0.18, p = .04) were associated with higher preparedness. Speaking French as a dominant language and physician role (vs. nurse) were negatively associated with preparedness (β = -0.26, p = .01; β = -0.22, p = .01). INSIGHTS: The state of cross-cultural care preparedness among Lausanne's front-line healthcare providers leaves room for improvement. Our study points toward institutional strategies to improve preparedness: notably, making sure departments are sensitized to cross-cultural care resources and increasing provider diversity to reflect the changing Swiss demographic.

Are multifaceted interventions more effective than single-component interventions in changing health-care professionals' behaviours? An overview of systematic reviews

Background

One of the greatest challenges in healthcare is how to best translate research evidence into clinical practice, which includes how to change health-care professionals’ behaviours. A commonly held view is that multifaceted interventions are more effective than single-component interventions. The purpose of this study was to conduct an overview of systematic reviews to evaluate the effectiveness of multifaceted interventions in comparison to single-component interventions in changing health-care professionals’ behaviour in clinical settings.

Methods

The Rx for Change database, which consists of quality-appraised systematic reviews of interventions to change health-care professional behaviour, was used to identify systematic reviews for the overview. Dual, independent screening and data extraction was conducted. Included reviews used three different approaches (of varying methodological robustness) to evaluate the effectiveness of multifaceted interventions: (1) effect size/dose-response statistical analyses, (2) direct (non-statistical) comparisons of multifaceted to single interventions and (3) indirect comparisons of multifaceted to single interventions.

Results

Twenty-five reviews were included in the overview. Three reviews provided effect size/dose-response statistical analyses of the effectiveness of multifaceted interventions; no statistical evidence of a relationship between the number of intervention components and the effect size was found. Eight reviews reported direct (non-statistical) comparisons of multifaceted to single-component interventions; four of these reviews found multifaceted interventions to be generally effective compared to single interventions, while the remaining four reviews found that multifaceted interventions had either mixed effects or were generally ineffective compared to single interventions. Twenty-three reviews indirectly compared the effectiveness of multifaceted to single interventions; nine of which also reported either a statistical (dose-response) analysis (N = 2) or a non-statistical direct comparison (N = 7). The majority (N = 15) of reviews reporting indirect comparisons of multifaceted to single interventions showed similar effectiveness for multifaceted and single interventions when compared to controls. Of the remaining eight reviews, six found single interventions to be generally effective while multifaceted had mixed effectiveness.

Conclusion

This overview of systematic reviews offers no compelling evidence that multifaceted interventions are more effective than single-component interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0152-6) contains supplementary material, which is available to authorized users.

Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study

Background

Cultural interventions offer the hope and promise of healing from addictions for Indigenous people.^a However, there are few published studies specifically examining the type and impact of these interventions. Positioned within the Honouring Our Strengths: Culture as Intervention project, a scoping study was conducted to describe what is known about the characteristics of culture-based programs and to examine the outcomes collected and effects of these interventions on wellness.

Methods

This review followed established methods for scoping studies, including a final stage of consultation with stakeholders. The data search and extraction were also guided by the “PICO” (Patient/population, Intervention, Comparison, and Outcome) method, for which we defined each element, but did not require direct comparisons between treatment and control groups. Twelve databases from the scientific literature and 13 databases from the grey literature were searched up to October 26, 2012.

Results

The search strategy yielded 4,518 articles. Nineteen studies were included from the United States (58%) and Canada (42%), that involved residential programs (58%), and all (100%) integrated Western and culture-based treatment services. Seventeen types of cultural interventions were found, with sweat lodge ceremonies the most commonly (68%) enacted. Study samples ranged from 11 to 2,685 clients. Just over half of studies involved quasi-experimental designs (53%). Most articles (90%) measured physical wellness, with fewer (37%) examining spiritual health. Results show benefits in all areas of wellness, particularly by reducing or eliminating substance use problems in 74% of studies.

Conclusions

Evidence from this scoping study suggests that the culture-based interventions used in addictions treatment for Indigenous people are beneficial to help improve client functioning in all areas of wellness. There is a need for well-designed studies to address the question of best relational or contextual fit of cultural practices given a particular place, time, and population group. Addiction researchers and treatment providers are encouraged to work together to make further inroads into expanding the study of culture-based interventions from multiple perspectives and locations.

The use of a collaborative structured methodology for the development of a multifaceted intervention programme for the management of asthma (the MIA project), tailored to the needs of children and families of South Asian origin: a community-based, participatory study

Background

Asthma is one of the most common chronic childhood illnesses in the UK. South Asian children are more likely to suffer from their asthma and be admitted to hospital. While this inequality needs to be addressed, standard behaviour-change interventions are known to be less successful in minority ethnic groups. Evidence suggests a need to enhance services provided to ethnic minority communities by developing culturally sensitive tailored interventions.

Objectives

The Management and Interventions for Asthma (MIA) project aimed to test an iterative multiphase participatory approach to intervention development underpinned by the socioecological model of health, producing an intervention-planning framework and enhancing an evidence-based understanding of asthma management in South Asian and White British children.

Design

Interviews and focus groups facilitated by community facilitators (CFs) were used to explore knowledge and perceptions of asthma among South Asian communities, children, families and healthcare professionals (HCPs). A smaller comparison group of White British families was recruited to identify aspects of asthma management that could be addressed either by generic interventions or by a tailored approach. Collaborative workshops were held to develop an intervention planning framework and to prioritise an aspect of asthma management that would be used as an exemplar for the development of the tailored, multifaceted asthma intervention programme.

Setting

The community study was based in a largely urban environment in Leicester, UK.

Participants

Participants were recruited directly from the South Asian (Indian, Pakistani and Bangladeshi) and White British communities, and through the NHS. Children were aged between 4 and 12 years, with a range of asthma severity.

Intervention development

The study had four phases. Phase 1 consisted of an evidence review of barriers and facilitators to asthma management in South Asian children. Phase 2 explored lay understandings of childhood asthma and its management among South Asian community members (n = 63). Phase 3 explored perceptions and experiences of asthma management among South Asian (n = 82) and White British families (n = 31) and HCP perspectives (n = 37). Using a modified intervention mapping approach incorporating psychological theory, phase 4 developed an intervention planning framework addressing the whole asthma pathway leading to the development of an exemplar multifaceted, integrated intervention programme called ‘ACT [Awareness, Context (cultural and organisational) and Training] on Asthma’.

Results

Data on the social patterning of perceptions of asthma and a lack of alignment between the organisation of health services, and the priorities and competencies of British South Asian communities and families were produced. Eleven key problem areas along the asthma pathway were identified. A four-arm multifaceted tailored programme, ‘ACT on Asthma’, was developed, focusing on the theme ‘getting a diagnosis’. This theme was chosen following prioritisation by families during the collaborative workshops, demonstrating the participatory, iterative, phased approach used for the intervention design.

Conclusions

The MIA study demonstrated barriers to optimal asthma management in children at the family, provider and healthcare system levels and across the whole asthma pathway. Interventions need to address each of these levels to be effective. Minority ethnic communities can be successfully engaged in collaborative intervention development with a community-focused and culturally sensitive methodology.

Future work

Further research is required to (1) assess the feasibility and effectiveness of the proposed ‘ACT on Asthma’ programme, (2) develop methods to increase active participation of children in research and service development, (3) develop and test strategies to enhance public understanding of asthma in South Asian communities and (4) identify effective means of engaging the wider family in optimising asthma management.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Is health a right for all? An umbrella review of the barriers to health care access faced by migrants

OBJECTIVE

To synthesise the scientific evidence concerning barriers to health care access faced by migrants. We sought to critically analyse this evidence with a view to guiding policies.

DESIGN

A systematic review methodology was used to identify systematic and scoping reviews which quantitatively or qualitatively analysed data from primary studies. The main variables analysed were structural and contextual barriers (health system organisation) as well as individual (patients and providers). The quality of evidence from the systematic reviews was critically appraised. From 2674 reviews, 79 were retained for further scrutiny, and finally 9 met the inclusion criteria.

RESULTS

The structural barriers identified were the lack of health insurance and the high cost of drugs (non-universal health system) and organisational aspects of health system (social insurance system and national health system). The individual barriers were linguistic and cultural. None of the reviews provided a quality appraisal of the studies.

CONCLUSIONS

Barriers to health care for migrants range from entitlement in non-universal health systems to accessibility in universal ones, and determinants of access to the respective health services should be analysed within the corresponding national context. Generate social and institutional changes that eliminate barriers to access to health services is essential to ensure health for all.

A longitudinal linear model of patient characteristics to predict failure to attend an inner-city chronic pain clinic

Patients often fail to attend appointments in chronic pain clinics for unknown reasons. We hypothesized that certain patient characteristics predict failure to attend scheduled appointments, pointing to systematic barriers to accessing chronic pain services for certain underserved populations. We collected retrospective data from a longitudinal observational cohort of patients at an academic pain clinic in Newark, New Jersey. To examine the effect of demographic factors on appointment status, we fit a marginal logistic regression using generalized estimating equations with exchangeable correlation. A total of 1,394 patients with 3,488 total encounters between January 1, 2006, and December 31, 2009, were included. Spanish spoken as a primary language (alternatively Hispanic or other race) and living between 5 and 10 miles from the clinic were associated with reduced odds of arriving for an appointment; making an appointment for a particular complaint such as cancer pain or back pain, an interventional pain procedure scheduled in connection with the appointment, unemployed status, and continuity of care (as measured by office visit number) were associated with increased odds of arriving. Spanish spoken as a primary language and distance to the pain clinic predicted failure to attend a scheduled appointment in our cohort. If these constitute systematic barriers to access, they may be amenable to targeted interventions.

PERSPECTIVE

We identified certain patient characteristics, specifically Spanish spoken as a primary language and geographic distance from the clinic, that predict failure to attend an inner-city chronic pain clinic. These identified barriers to accessing chronic pain services may be modifiable by simple cost-effective interventions.

Childhood socio-economic status and ethnic disparities in psychosocial outcomes in New Zealand

OBJECTIVE

The present study examined the extent to which childhood socio-economic status (SES) could account for differences in adult psychosocial outcomes between Māori and non-Māori individuals in a birth cohort of more than 1000 individuals studied to age 30.

METHODS

Data were gathered on three measures of childhood SES (family SES, family living standards, family income) and adult psychosocial outcomes including mental health, substance use, criminal offending, and education/welfare dependence outcomes, as part of a longitudinal study of a New Zealand birth cohort (the Christchurch Health and Development Study).

RESULTS

Those reporting Māori ethnicity had significantly (p < 0.0001) poorer scores on the three measures of childhood SES, with estimates of Cohen's d indicating a moderate effect size. Māori cohort members also had significantly (p < 0.05) greater rates of adverse psychosocial outcomes in adulthood. Controlling for childhood SES reduced the magnitude of the ethnic differences in psychosocial outcomes, but did not fully explain the differences between Māori and non-Māori. Adjustment for childhood SES had the strongest effect on education/welfare dependence, but weaker effects on mental health, substance use, and criminal offending.

CONCLUSIONS

Improvements in SES among Māori in New Zealand may, to some extent, ameliorate the long standing disparities in psychosocial well-being between Māori and non-Māori. However, efforts to improve Māori well-being will require an approach that moves beyond a sole focus on rectifying socio-economic disadvantage.

Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview

OBJECTIVE

Conduct a global situational analysis to identify the current facilitators and barriers to improving quality of care (QoC) for pregnant women, newborns and children.

STUDY DESIGN

Metareview of published and unpublished systematic reviews and meta-analyses conducted between January 2000 and March 2013 in any language. Assessment of Multiple Systematic Reviews (AMSTAR) is used to assess the methodological quality of systematic reviews.

SETTINGS

Health systems of all countries. Study outcome: QoC measured using surrogate indicators--effective, efficient, accessible, acceptable/patient centred, equitable and safe.

ANALYSIS

Conducted in two phases (1) qualitative synthesis of extracted data to identify and group the facilitators and barriers to improving QoC, for each of the three population groups, into the six domains of WHO's framework and explore new domains and (2) an analysis grid to map the common facilitators and barriers.

RESULTS

We included 98 systematic reviews with 110 interventions to improve QoC from countries globally. The facilitators and barriers identified fitted the six domains of WHO's framework--information, patient-population engagement, leadership, regulations and standards, organisational capacity and models of care. Two new domains, 'communication' and 'satisfaction', were generated. Facilitators included active and regular interpersonal communication between users and providers; respect, confidentiality, comfort and support during care provision; engaging users in decision-making; continuity of care and effective audit and feedback mechanisms. Key barriers identified were language barriers in information and communication; power difference between users and providers; health systems not accounting for user satisfaction; variable standards of implementation of standard guidelines; shortage of resources in health facilities and lack of studies assessing the role of leadership in improving QoC. These were common across the three population groups.

CONCLUSIONS

The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects. Adopting the identified facilitators would help countries strengthen their health systems and ensure high-quality care for all.

Diabetes health information technology innovation to improve quality of life for health plan members in urban safety net

Safety net systems need innovative diabetes self-management programs for linguistically diverse patients. A low-income government-sponsored managed care plan implemented a 27-week automated telephone self-management support/health coaching intervention for English-, Spanish-, and Cantonese-speaking members from 4 publicly funded clinics in a practice-based research network. Compared to waitlist, immediate intervention participants had greater 6-month improvements in overall diabetes self-care behaviors (standardized effect size [ES] = 0.29, P < .01) and 12-Item Short Form Health Survey physical scores (ES = 0.25, P = .03); changes in patient-centered processes of care and cardiometabolic outcomes did not differ. Automated telephone self-management is a strategy for improving patient-reported self-management and may also improve some outcomes.

Culturally adapted hypertension education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: cluster-randomized trial

Objectives

To evaluate the effect of a practice-based, culturally appropriate patient education intervention on blood pressure (BP) and treatment adherence among patients of African origin with uncontrolled hypertension.

Methods

Cluster randomised trial involving four Dutch primary care centres and 146 patients (intervention n = 75, control n = 71), who met the following inclusion criteria: self-identified Surinamese or Ghanaian; ≥20 years; treated for hypertension; SBP≥140 mmHg. All patients received usual hypertension care. The intervention-group was also offered three nurse-led, culturally appropriate hypertension education sessions. BP was assessed with Omron 705-IT and treatment adherence with lifestyle- and medication adherence scales.

Results

139 patients (95%) completed the study (intervention n = 71, control n = 68). Baseline characteristics were largely similar for both groups. At six months, we observed a SBP reduction of ≥10 mmHg -primary outcome- in 48% of the intervention group and 43% of the control group. When adjusted for pre-specified covariates age, sex, hypertension duration, education, baseline measurement and clustering effect, the between-group difference was not significant (OR; 0.42; 95% CI: 0.11 to 1.54; P = 0.19). At six months, the mean SBP/DBD had dropped by 10/5.7 (SD 14.3/9.2)mmHg in the intervention group and by 6.3/1.7 (SD 13.4/8.6)mmHg in the control group. After adjustment, between-group differences in SBP and DBP reduction were −1.69 mmHg (95% CI: −6.01 to 2.62, P = 0.44) and −3.01 mmHg (−5.73 to −0.30, P = 0.03) in favour of the intervention group. Mean scores for adherence to lifestyle recommendations increased in the intervention group, but decreased in the control group. Mean medication adherence scores improved slightly in both groups. After adjustment, the between-group difference for adherence to lifestyle recommendations was 0.34 (0.12 to 0.55; P = 0.003). For medication adherence it was −0.09 (−0.65 to 0.46; P = 0.74).

Conclusion

This intervention led to significant improvements in DBP and adherence to lifestyle recommendations, supporting the need for culturally appropriate hypertension care.

Trial Registration

Controlled-Trials.com ISRCTN35675524

The role of at-risk alcohol/drug use and treatment in appointment attendance and virologic suppression among HIV(+) African Americans

The causes of poor clinic attendance and incomplete virologic suppression among HIV(+) African Americans (AAs) are not well understood. We estimated the effect of at-risk alcohol/drug use and associated treatment on attending scheduled appointments and virologic suppression among 576 HIV(+) AA patients in the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort who contributed 591 interviews to the analysis. At interview, 78% of patients were new to HIV care at UAB, 38% engaged in at-risk alcohol/drug use or received associated treatment in the prior year, while the median (quartiles) age and CD4 count were 36 (28; 46) years and 321 (142; 530) cells/μl, respectively. In the 2 years after an interview, half of the patients had attended at least 82% of appointments while half had achieved virologic suppression for at least 71% of RNA assessments. Compared to patients who did not use or receive treatment, the adjusted risk ratio (aRR) for attending appointments for patients who did use but did not receive treatment was 0.97 (95% confidence limits: 0.92, 1.03). The corresponding aRR for virologic suppression was 0.94 (0.86, 1.03). Compared to patients who did not receive treatment but did use, the aRR for attending appointments for patients who did receive treatment and did use was 0.86 (0.78, 0.95). The corresponding aRR for virologic suppression was 1.07 (0.92, 1.24). Use was negatively associated with attendance and virologic suppression among patients not in treatment. Among users, treatment was negatively associated with attendance yet positively associated with virologic suppression. However, aRR estimates were imprecise.

Cultural competency of health-care providers in a Swiss University Hospital: self-assessed cross-cultural skillfulness in a cross-sectional study

BACKGROUND

As the diversity of the European population evolves, measuring providers' skillfulness in cross-cultural care and understanding what contextual factors may influence this is increasingly necessary. Given limited information about differences in cultural competency by provider role, we compared cross-cultural skillfulness between physicians and nurses working at a Swiss university hospital.

METHODS

A survey on cross-cultural care was mailed in November 2010 to front-line providers in Lausanne, Switzerland. This questionnaire included some questions from the previously validated Cross-Cultural Care Survey. We compared physicians' and nurses' mean composite scores and proportion of "3-good/4-very good" responses, for nine perceived skillfulness items (4-point Likert-scale) using the validated tool. We used linear regression to examine how provider role (physician vs. nurse) was associated with composite skillfulness scores, adjusting for demographics (gender, non-French dominant language), workplace (time at institution, work-unit "sensitized" to cultural-care), reported cultural-competence training, and cross-cultural care problem-awareness.

RESULTS

Of 885 questionnaires, 368 (41.2%) returned the survey: 124 (33.6%) physicians and 244 (66.4%) nurses, reflecting institutional distribution of providers. Physicians had better mean composite scores for perceived skillfulness than nurses (2.7 vs. 2.5, p < 0.005), and significantly higher proportion of "good/very good" responses for 4/9 items. After adjusting for explanatory variables, physicians remained more likely to have higher skillfulness (β = 0.13, p = 0.05). Among all, higher skillfulness was associated with perception/awareness of problems in the following areas: inadequate cross-cultural training (β = 0.14, p = 0.01) and lack of practical experience caring for diverse populations (β = 0.11, p = 0.04). In stratified analyses among physicians alone, having French as a dominant language (β = -0.34, p < 0.005) was negatively correlated with skillfulness.

CONCLUSIONS

Overall, there is much room for cultural competency improvement among providers. These results support the need for cross-cultural skills training with an inter-professional focus on nurses, education that attunes provider awareness to the local issues in cross-cultural care, and increased diversity efforts in the work force, particularly among physicians.

An investigation of culturally competent terminology in healthcare policy finds ambiguity and lack of definition

OBJECTIVE

This research explored how the concept of cultural competence was represented and expressed through health policies that were intended to improve the quality and efficacy of healthcare provided to families from culturally marginalised communities, particularly women and children with refugee backgrounds.

METHOD

A critical document analysis was conducted of policies that inform healthcare for families from culturally marginalised communities in two local government areas in South Australia.

RESULTS

The analysis identified two major themes: lack of, or inconsistent, definitions of 'culture' and 'cultural competency' and related terms; and the paradoxical use of language to determine care.

CONCLUSIONS

Cultural competence within health services has been identified as an important factor that can improve the health outcomes for families from marginalised communities. However, inconsistency in definitions, understanding and implementation of cultural competence in health practice makes it difficult to implement care using these frameworks.

IMPLICATIONS

Clearly defined pathways are necessary from health policy to inform culturally competent service delivery. The capacity for policy directives to effectively circumvent the potential deleterious outcomes of culturally incompetent services is only possible when that policy provides clear definitions and instructions. Consultation and partnership are necessary to develop effective definitions and processes relating to cultural competence.

Culturally competent interventions in Type 2 diabetes mellitus management: an equity-oriented literature review

OBJECTIVES

Although, culturally competent (CC) interventions aim to reduce health inequalities for ethnic minorities, they have been criticized on the grounds that they increase prejudice and stereotyping. It remains unclear whether CC interventions really can reduce health inequalities among ethnic minorities. The purpose of this review is to assess whether CC interventions in the management of Type 2 diabetes mellitus (T2DM) match the recommendations to reduce health inequalities.

DESIGN

We identified CC interventions relating to T2DM among ethnic minority patients in the literature published between 2005 and 2011. Data were analyzed according to an equity-oriented framework. Each study was given a score based on its congruence with the reduction of health inequalities amongst ethnic minorities.

RESULTS

We reviewed 137 papers and found 61 studies that met the inclusion criteria. Most interventions focused on the individual level and the modification of patients' health behavior. Very few addressed the sociopolitical level. A minority of the studies acknowledged the role of socioeconomic deprivation in ethnic health inequalities. Half of the studies contained no information about the socioeconomic status of the patients. The patients receiving the interventions were socioeconomically deprived. Only 10 studies compared ethnic minority groups to majority groups. Thirty-three studies had a very low average congruence score. The highest score of congruence was achieved by one study.

CONCLUSION

Overall, CC interventions addressing T2DM are not congruent with the reduction of ethnic health inequalities. The future of CC interventions may involve going one step further and going back to basic tenets of cultural competence: the integration of difference, whatever its source, into the delivery of fair health care for patients.

Diabetes care and service access among elderly Vietnamese with type 2 diabetes

BACKGROUND

Vietnamese patients are disproportionately represented in type 2 diabetes mellitus statistics and also incur high rates of diabetes complications. This situation is compounded by limited access to health care. The aim of this project was to gain a deeper understanding of the difficulties Vietnamese patients experience when accessing services and managing their type 2 diabetes mellitus, and to identify factors that are important in promoting health service use.

METHODS

Three focus groups with 15 Vietnamese participants with type 2 diabetes mellitus, 60 to >70 years of age, were conducted in Vietnamese. Open-ended questions were used and focussed on experiences of living with diabetes and access to healthcare services in the Inner Northwest Melbourne region. Audio recordings were transcribed and then translated into English. Data were analysed using a thematic analysis framework.

RESULTS

Findings indicate four main themes, which together provide some insight into the experiences of living with diabetes and accessing ongoing care and support, for elderly Vietnamese with type 2 diabetes. Themes included: (1) the value of being healthy; (2) controlling diabetes; (3) staying healthy; and (4) improving services and information access.

CONCLUSIONS

Participants in this study were encouraged to adhere to diabetes self-management principles, based largely on a fear of medical complications. Important aspects of healthcare access were identified as; being treated with respect, having their questions answered and having access to interpreters and information in Vietnamese. Attention to these details is likely to lead to improved access to healthcare services and ultimately to improve glycemic control and overall health status for this community.

Communication in cross-cultural consultations in primary care in Europe: the case for improvement. The rationale for the RESTORE FP 7 project

The purpose of this paper is to substantiate the importance of research about barriers and levers to the implementation of supports for cross-cultural communication in primary care settings in Europe. After an overview of migrant health issues, with the focus on communication in cross-cultural consultations in primary care and the importance of language barriers, we highlight the fact that there are serious problems in routine practice that persist over time and across different European settings. Language and cultural barriers hamper communication in consultations between doctors and migrants, with a range of negative effects including poorer compliance and a greater propensity to access emergency services. It is well established that there is a need for skilled interpreters and for professionals who are culturally competent to address this problem. A range of professional guidelines and training initiatives exist that support the communication in cross-cultural consultations in primary care. However, these are commonly not implemented in daily practice. It is as yet unknown why professionals do not accept or implement these guidelines and interventions, or under what circumstances they would do so. A new study involving six European countries, RESTORE (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings), aims to address these gaps in knowledge. It uses a unique combination of a contemporary social theory, normalisation process theory (NPT) and participatory learning and action (PLA) research. This should enhance understanding of the levers and barriers to implementation, as well as providing stakeholders, with the opportunity to generate creative solutions to problems experienced with the implementation of such interventions.

Fifteen-year trends in awareness of heart disease in women: results of a 2012 American Heart Association national survey

BACKGROUND

The purpose of this study was to evaluate trends in awareness of cardiovascular disease (CVD) risk among women between 1997 and 2012 by racial/ethnic and age groups, as well as knowledge of CVD symptoms and preventive behaviors/barriers.

METHODS AND RESULTS

A study of awareness of CVD was conducted by the American Heart Association in 2012 among US women >25 years of age identified through random-digit dialing (n=1205) and Harris Poll Online (n=1227), similar to prior American Heart Association national surveys. Standardized questions on awareness were given to all women; additional questions about preventive behaviors/barriers were given online. Data were weighted, and results were compared with triennial surveys since 1997. Between 1997 and 2012, the rate of awareness of CVD as the leading cause of death nearly doubled (56% versus 30%; P<0.001). The rate of awareness among black and Hispanic women in 2012 (36% and 34%, respectively) was similar to that of white women in 1997 (33%). In 1997, women were more likely to cite cancer than CVD as the leading killer (35% versus 30%), but in 2012, the trend reversed (24% versus 56%). Awareness of atypical symptoms of CVD has improved since 1997 but remains low. The most common reasons why women took preventive action were to improve health and to feel better, not to live longer.

CONCLUSIONS

Awareness of CVD among women has improved in the past 15 years, but a significant racial/ethnic minority gap persists. Continued effort is needed to reach at-risk populations. These data should inform public health campaigns to focus on evidenced-based strategies to prevent CVD and to help target messages that resonate and motivate women to take action.

The challenge of asthma in minority populations

The burden and disparity of asthma in race/ethnic minorities present a significant challenge. In this review, we will evaluate data on asthma epidemiology in minorities, examine potential reasons for asthma disparities, and discuss strategies of intervention and culturally sensitive care.

Exploring ways to overcome barriers to mammography uptake and retention among South Asian immigrant women

South Asians comprise one of the fastest growing immigrant groups in North America. Evidence indicates that South Asian (SA) immigrant women are vulnerable to low rates of breast cancer screening. Yet, there is a dearth of knowledge pertaining to socioculturally tailored strategies to guide the uptake of screening mammography in the SA community. In 2010, the authors conducted semi-structured focus groups (FG) to elicit perspectives of health and social service professionals on possible solutions to barriers identified by SA immigrant women in a recent study conducted in the Greater Toronto Area. Thirty-five health and social services staff members participated in five FG. The discussions were audio taped and detailed field notes were taken. All collected data were transcribed verbatim and thematic analysis was conducted using techniques of constant comparison within and across the group discussions. Three dominant themes were identified: (i) 'Target and Tailor' focused on awareness raising through multiple direct and indirect modes or approaches with underlying shared processes of involving men and the whole family, use of first language and learning from peers; (ii) 'Enhancing Access to Services' included a focus on 'adding ancillary services' and 'reinforcement of existing services' including expansion to a one-stop model; and (iii) 'Meta-Characteristics' centred on providing 'multi-pronged' approaches to reach the community, and 'sustainability' of initiatives by addressing structural barriers of adequate funding, healthcare provider mix, inter-sectoral collaboration and community voice. The findings simultaneously shed light on the grassroot practical strategies and the system level changes to develop efficient programmes for the uptake of mammography among SA immigrant women. The parallel focus on the 'Target and Tailor' and 'Enhancing Access to Services' calls for co-ordination at the policy level so that multiple sectors work jointly to streamline resources, or meta-characteristics.

REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol

BACKGROUND

The implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology--Participatory Learning and Action--to investigate and support implementation of such guidelines and training initiatives in routine practice.

METHODS

This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders-migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory's four constructs--coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings.

DISCUSSION

This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

Characteristics of primary care safety-net providers and their quality improvement attitudes and activities: results of a national survey of physician professionalism

No current national data exist to characterize safety-net physicians and their attitudes toward and participation in quality improvement activities compared with non-safety-net physicians. The authors conducted a national random sample survey of internal medicine, family practice, and pediatrics primary care physicians (PCPs) and used weighted multivariable regression models to assess attitudes and participation in quality improvement activities. After multivariable adjustment, there were no significant differences in provider attitudes about or participation in quality improvement activities between safety-net and non-safety-net physicians. However, safety-net providers were almost twice as likely to look for racial/ethnic disparities in care within their practices and are as likely to be involved in quality improvement activities as non-safety-net providers; their attitudes are consistent with providing equitable and universal care. Increasing access by expanding Medicaid eligibility will require continued investment in the number and training of safety-net PCPs.

Multilevel interventions and racial/ethnic health disparities

To examine the impact of multilevel interventions (with three or more levels of influence) designed to reduce health disparities, we conducted a systematic review and meta-analysis of interventions for ethnic/racial minorities (all except non-Hispanic whites) that were published between January 2000 and July 2011. The primary aims were to synthesize the findings of studies evaluating multilevel interventions (three or more levels of influence) targeted at ethnic and racial minorities to reduce disparities in their health care and obtain a quantitative estimate of the effect of multilevel interventions on health outcomes among these subgroups. The electronic database PubMed was searched using Medical Subject Heading terms and key words. After initial review of abstracts, 26 published studies were systematically reviewed by at least two independent coders. Those with sufficient data (n = 12) were assessed by meta-analysis and examined for quality using a modified nine-item Physiotherapy Evidence Database coding scheme. The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes, including cancer prevention and screening, as well improving the quality of health-care system processes. The weighted average effect size across studies for all health behavior outcomes reported at the individual participant level (k = 17) was odds ratio (OR) = 1.27 (95% confidence interval [CI] = 1.11 to 1.44); for the outcomes reported by providers or organizations, the weighted average effect size (k = 3) was OR = 2.53 (95% CI = 0.82 to 7.81). Enhanced application of theories to multiple levels of change, novel design approaches, and use of cultural leveraging in intervention design and implementation are proposed for this nascent field.

Clinicians' views of an intervention to reduce racial disparities in diabetes outcomes

RATIONALE

Interventions that improve clinicians' awareness of racial disparities and improve their communication skills are considered promising strategies for reducing disparities in health care. We report clinicians' views of an intervention involving cultural competency training and race-stratified performance reports designed to reduce racial disparities in diabetes outcomes.

RESEARCH DESIGN AND METHODS

Semistructured interviews were conducted with 12 physicians and 5 nurse practitioners who recently participated in a randomized intervention to reduce racial disparities in diabetes outcomes. Clinicians were asked open-ended questions about their attitudes towards the intervention, the causes of disparities, and potential solutions to them.

RESULTS

Thematic analysis of the interviews showed that most clinicians acknowledged the presence of racial disparities in diabetes control among their patients. They described a complex set of causes, including socioeconomic factors, but perceived only some causes to be within their power to change, such as switching patients to less-expensive generic drugs. The performance reports and training were generally well received but some clinicians did not feel empowered to act on the information. All clinicians identified additional services that would help them address disparities; for example, culturally tailored nutrition advice. Some clinicians challenged the premise of the intervention, focusing instead on socioeconomic factors as the primary cause of disparities rather than on patients' race.

CONCLUSIONS

The cultural competency training and performance reports were well received by many but not all of the clinicians. Clinicians reported the intervention alone had not empowered them to address the complex, root causes of racial disparities in diabetes outcomes.

Quasi-experimental trial of diabetes Self-Management Automated and Real-Time Telephonic Support (SMARTSteps) in a Medicaid managed care plan: study protocol

Background

Health information technology can enhance self-management and quality of life for patients with chronic disease and overcome healthcare barriers for patients with limited English proficiency. After a randomized controlled trial of a multilingual automated telephone self-management support program (ATSM) improved patient-centered dimensions of diabetes care in safety net clinics, we collaborated with a nonprofit Medicaid managed care plan to translate research into practice, offering ATSM as a covered benefit and augmenting ATSM to promote medication activation. This paper describes the protocol of the Self-Management Automated and Real-Time Telephonic Support Project (SMARTSteps).

Methods/Design

This controlled quasi-experimental trial used a wait-list variant of a stepped wedge design to enroll 362 adult health plan members with diabetes who speak English, Cantonese, or Spanish and receive care at 4 publicly-funded clinics. Through language-stratified randomization, participants were assigned to four intervention statuses: SMARTSteps-ONLY, SMARTSteps-PLUS, or wait-list for either intervention. In addition to usual primary care, intervention participants received 27 weekly calls in their preferred language with rotating queries and response-triggered education about self-care, medication adherence, safety concerns, psychological issues, and preventive services. Health coaches from the health plan called patients with out-of-range responses for collaborative goal setting and action planning. SMARTSteps-PLUS also included health coach calls to promote medication activation, adherence and intensification, if triggered by ATSM-reported non-adherence, refill non-adherence from pharmacy claims, or suboptimal cardiometabolic indicators. Wait-list patients crossed-over to SMARTSteps-ONLY or -PLUS at 6 months. For participants who agreed to structured telephone interviews at baseline and 6 months (n = 252), primary outcomes will be changes in quality of life and functional status with secondary outcomes of 6-month changes in self-management behaviors/efficacy and patient-centered processes of care. We will also evaluate 6-month changes in cardiometabolic (HbA1c, blood pressure, and LDL) and utilization indicators for all participants.

Discussion

Outcomes will provide evidence regarding real-world implementation of ATSM within a Medicaid managed care plan serving safety net settings. The evaluation trial will provide insight into translating and scaling up health information technology interventions for linguistically and culturally diverse vulnerable populations with chronic disease.

Trial Registration

ClinicalTrials.gov: NCT00683020

The landscape of knowledge translation interventions in cancer control: what do we know and where to next? A review of systematic reviews

Background

Effective implementation strategies are needed to optimize advancements in the fields of cancer diagnosis, treatment, survivorship, and end-of-life care. We conducted a review of systematic reviews to better understand the evidentiary base of implementation strategies in cancer control.

Methods

Using three databases, we conducted a search and identified English-language systematic reviews published between 2005 and 2010 that targeted consumer, professional, organizational, regulatory, or financial interventions, tested exclusively or partially in a cancer context (primary focus); generic or non-cancer-specific reviews were also considered. Data were extracted, appraised, and analyzed by members of the research team, and research ideas to advance the field were proposed.

Results

Thirty-four systematic reviews providing 41 summaries of evidence on 19 unique interventions comprised the evidence base. AMSTAR quality ratings ranged between 2 and 10. Team members rated most of the interventions as promising and in need of further research, and 64 research ideas were identified.

Conclusions

While many interventions show promise of effectiveness in the cancer-control context, few reviews were able to conclude definitively in favor of or against a specific intervention. We discuss the complexity of implementation research and offer suggestions to advance the science in this area.

Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities

BACKGROUND

Racial and ethnic disparities in health care have been consistently documented in the diagnosis, treatment, and outcomes of many common clinical conditions. There has been an acceleration of health information technology (HIT) implementation in the United States, with health care reform legislation including multiple provisions for collecting and using health information to improve and monitor quality and efficiency in health care. Despite an uneven and generally low level of implementation, research has demonstrated that HIT has the potential to improve quality of care and patient safety. If carefully designed and implemented, HIT also has the potential to eliminate disparities.

HIT AND DISPARITIES

Several root causes for disparities are amenable to interventions using HIT, particularly innovations in electronic health records, as well as strategies for chronic disease management. Recommendations regardinghealth care system, provider, and patient factors can help health care organizations address disparities as they adopt, expand, and tailor their HIT systems. In terms of health care system factors, organizations should (1) automate and standardize the collection of race/ethnicity and language data, (2) prioritize the use of the data for identifying disparities and tailoring improvement efforts, (3) focus HIT efforts to address fragmented care delivery for racial/ethnic minorities and limited-English-proficiency patients, (4) develop focused computerized clinical decision support systems for clinical areas with significant disparities, and (5) include input from racial/ethnic minorities and those with limited English proficiency in developing patient HIT tools to address the digital divide.

CONCLUSIONS

As investments are made in HIT, consideration must be given to the impact that these innovations have on the quality and cost of health care for all patients, including those who experience disparities.

Leveraging quality improvement to achieve equity in health care

INEQUALITY IN QUALITY: Disparities in health care and quality for racial, ethnic, linguistic, and other disadvantaged groups are widespread and persistent. Health care organizations are engaged in efforts to improve quality in general but often make little attempt to address disparities.

STANDARD VERSUS CULTURALLY COMPETENT QUALITY IMPROVEMENT (QI)

Most QI interventions are broadly targeted to the general population-a "one-size-fits-all" approach. These standard QI efforts may preferentially improve quality for more advantaged patients and maintain or even worsen existing disparities. Culturally competent QI interventions place specific emphasis on addressing the unique needs of minority groups and the root causes of disparities.

HOW QI CAN REDUCE DISPARITIES

QI interventions can reduce disparities in at least three ways: (1) In some cases, standard QI interventions can improve quality more for those with the lowest quality, but this is unreliable; (2) group-targeted QI interventions can reduce disparities by preferentially targeting disparity groups; and (3) culturally competent QI interventions, by tailoring care to cultural and linguistic barriers that cause disparities, can improve care for everyone but especially for disparity groups.

GUIDELINES FOR CULTURALLY COMPETENT QI

A culturally competent approach to QI should (1) identify disparities and use disparities data to guide and monitor interventions, (2) address barriers unique to specific disparity groups, and (3) address barriers common to many disparity group.

CONCLUSIONS

To achieve equity in health care, hospitals and other health care organizations should move toward culturally competent QI and disparities-targeted QI interventions to achieve equity in health care, a key pillar of quality.

Collaborative depression care management and disparities in depression treatment and outcomes

CONTEXT

Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes.

OBJECTIVE

To examine the effects of DCM on treatment disparities by education and race/ethnicity in older depressed primary care patients.

DESIGN

Analysis of data from the randomized controlled trial Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).

SETTING

Twenty primary care practices.

PARTICIPANTS

A total of 396 individuals 60 years or older with major depression. We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by race/ethnicity (and vice versa).

INTERVENTION

Algorithm-based recommendations to physicians and care management by care managers.

MAIN OUTCOME MEASURES

Antidepressant use, depressive symptoms, and intensity of DCM over 2 years.

RESULTS

The PROSPECT intervention had a larger and more lasting effect in less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) (95% confidence interval [CI], 1.7 to 26.4 pps) in the no-college group compared with a null effect in the college-educated group (-9.2 pps [95% CI, -25.0 to 2.7 pps]); at month 24, the intervention reduced depressive symptoms by 2.6 pps on the Hamilton Depression Rating Scale (95% CI, -4.6 to -0.4 pps) in no-college patients, 3.8 pps (95% CI, -6.8 to -0.4) more than in the college group. The intervention benefitted non-Hispanic white patients more than minority patients. Intensity of DCM received by minorities was 60% to 70% of that received by white patients after the initial phase but did not differ by education.

CONCLUSIONS

The PROSPECT intervention substantially reduced disparities by patient education but did not mitigate racial/ethnic disparities in depression treatment and outcomes. Incorporation of culturally tailored strategies in DCM models may be needed to extend their benefits to minorities.

TRIAL REGISTRATION

clinicaltrials.gov Identifier for

PROSPECT

NCT00279682.

Reducing ethnic disparities in the quality of trauma care: an important research gap

OBJECTIVE

To identify interventions for reducing ethnic disparities in the quality of trauma care.

BACKGROUND

Variation in the quality of health care is recognized as an important contributor to ethnic disparities in many domains of health. Although recent articles document ethnic variations in the quality of trauma care in several countries, strategies that address these disparities have received little attention.

METHODS

Systematic review of intervention studies designed to reduce ethnic disparities in trauma care.

RESULTS

Our systematic literature review revealed no evaluations of interventions designed to reduce ethnic disparities in trauma care. A scan of the equivalent literature in other health care settings revealed 3 types of strategies that could serve as promising interventions that warrant further investigation in the trauma care setting: (1) improving cultural competency of service providers, (2) addressing the effects of health literacy on the quality of trauma care, and (3) quality improvement strategies that recognize equity as a key dimension of quality. The trauma coordinator role may help address some aspects relating to these themes although reducing disparities is likely to require broader system-wide policies.

CONCLUSIONS

The implementation and robust evaluation of strategies designed to reduce ethnic disparities in trauma care are long overdue.

THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING

Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians' behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians' behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research

BACKGROUND

Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities.

OBJECTIVE

The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research.

DESIGN

The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included.

MEASUREMENTS

Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted.

RESULTS

Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect.

CONCLUSION

There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis

OBJECTIVE

To conduct a systematic review to identify and describe the scope and nature of the research evidence on the effectiveness of interventions to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis (OA) as an example of a common chronic disease.

METHODS

We searched electronic databases from 1950 through February 2010 and grey literature for relevant articles using any study design. Studies with interventions designed explicitly to improve health care quality or reduce disparities in the care of disadvantaged adult populations with OA and including an evaluation were eligible. We used the PROGRESS-Plus framework to identify disadvantaged population subgroups.

RESULTS

Of 4,701 citations identified, 10 met the inclusion criteria. Eight were community based and 6 targeted race/ethnicity/culture. All 10 studies evaluated interventions aimed at people with OA; 2 studies also targeted the health care system. No studies targeted health care providers. Nine of 10 studies evaluated arthritis self-management interventions; all showed some benefit. Only 1 study compared the difference in effect between the PROGRESS-Plus disadvantaged population and the relevant comparator group.

CONCLUSION

There are few studies evaluating the effectiveness of interventions to improve health care quality in disadvantaged populations with OA. Further research is needed to evaluate interventions aimed at health care providers and the health care system, as well as other patient-level interventions. Gap intervention research is also needed to evaluate whether interventions are effective in reducing documented health care inequities.

Barriers and enablers in the implementation of a provider-based intervention to stimulate culturally appropriate hypertension education

OBJECTIVE

to identify barriers and enablers influencing the implementation of an intervention to stimulate culturally appropriate hypertension education (CAHE) among health care providers in primary care.

METHODS

the intervention was piloted in three Dutch health centers. It consists of a toolkit for CAHE, training, and feedback meetings for hypertension educators. Data were collected from 16 hypertension educators (nurse practitioners and general practice assistants) during feedback meetings and analyzed using qualitative content analysis.

RESULTS

perceived barriers to the implementation of the intervention fell into three main categories: political context (health care system financing); organizational factors (ongoing organizational changes, work environment, time constraints and staffing) and care provider-related factors (routines, attitudes, computer and educational skills, and cultural background). Few barriers were specifically related to the delivery of CAHE (e.g. resistance to registering ethnicity). Enabling strategies addressing these barriers consisted of reorganizing practice procedures, team coordination, and providing reminders and additional instructions to hypertension educators.

CONCLUSION AND PRACTICE IMPLICATIONS

the adoption of a tool for CAHE by care providers can be accomplished if barriers are identified and addressed. The majority of these barriers are commonly associated with the implementation of health care innovations in general and do not indicate resistance to providing culturally appropriate care.

Adaptations to pain rehabilitation programmes for non-native patients with chronic pain

PURPOSE

(i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place.

SUBJECTS

Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme.

METHOD

A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ(2) tests or Fischer's exact tests and logistic regression analysis.

RESULTS

Twelve institutes (44.4%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9% of the institutes); longer consultations (25.9%) and education for employees regarding cultural competency (11.1%). Institutes which treated a high percentage (≥11%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p = 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees.

CONCLUSION

Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.

Racial and ethnic disparities in indicators of physical health status: do they still exist throughout late life?

Physical health problems become more common as people age and are associated with a great deal of disability. Although racial and ethnic disparities have been reported in physical health, little is known about whether these disparities remain in the latest part of older adulthood. Accordingly, the current study sought to examine racial and ethnic differences in the physical health status of three age groups of older adults, using the 2005 and 2007 California Health Interview Survey. The sample for the current study included 40,631 individuals aged 55 and older: 33,488 non-Hispanic whites, 1,858 blacks, 2,872 Asians and Pacific Islanders, and 2,412 Latinos. Respondents were compared with regard to three indicators of physical health: four chronic health conditions, difficulties with activities of daily living, and self-rated health. Analyses were conducted with and without adjustment for sex, marital status, education, English-language proficiency, nativity, and insurance status. Results revealed that, in general, racial and ethnic disparities existed for physical health in late adulthood, with differences less pronounced for Asians and Pacific Islanders and Latinos aged 75 and older after multivariable adjustment. Disparities between blacks and non-Hispanic whites and disparities across all racial and ethnic minorities in self-rated health still existed. These findings suggest that, to reduce racial and ethnic disparities, clinicians need to address specific sociodemographic and lifestyle factors related to racial and ethnic differences in health before these conditions are manifested in late adulthood.

Development of guidelines for recently arrived immigrants and refugees to Canada: Delphi consensus on selecting preventable and treatable conditions

BACKGROUND

Setting priorities is critical to ensure guidelines are relevant and acceptable to users, and that time, resources and expertise are used cost-effectively in their development. Stakeholder engagement and the use of an explicit procedure for developing recommendations are critical components in this process.

METHODS

We used a modified Delphi consensus process to select 20 high-priority conditions for guideline development. Canadian primary care practitioners who care for immigrants and refugees used criteria that emphasize inequities in health to identify clinical care gaps.

RESULTS

Nine infectious diseases were selected, as well as four mental health conditions, three maternal and child health issues, caries and periodontal disease, iron-deficiency anemia, diabetes and vision screening.

INTERPRETATION

Immigrant and refugee medicine covers the full spectrum of primary care, and although infectious disease continues to be an important area of concern, we are now seeing mental health and chronic diseases as key considerations for recently arriving immigrants and refugees.

Epidemiology of injury and the impact of health disparities

PURPOSE OF REVIEW

The purpose of this review is to highlight recent advances in understanding the epidemiology of pediatric trauma and the impact of health disparities on care of the injured child.

RECENT FINDINGS

Recent studies examining outcomes for injury in children consistently demonstrate worse clinical and functional outcomes for minority children compared with white children, with African-American race being an independent predictor of mortality. Despite controlling for injury severity and insurance status (as a surrogate of socioeconomic status), these disparities persist. Significant racial differences in mortality were also identified when national data were compared with local institutional data for children with traumatic brain injury. Studies examining the effect of insurance status on care of the injured child have similarly uncovered unsettling inequities. Disparities in delivery of pediatric trauma care have been identified based on access to pediatric trauma centers. Other studies have sought to reduce disparities by use of guidelines. Finally, prevention studies have demonstrated racial disparities in the use of motor vehicle restraints, with improved restraint use in minority populations after implementation of culturally tailored prevention programs.

SUMMARY

The cause of disparities in childhood trauma appears to be multifactorial and may include race, socioeconomic factors, insurance status, access, and healthcare provider biases. Multiple studies have confirmed that disparities exist, but it is difficult to tease out the reasons why they exist. Further work is necessary to identify causes of such disparities and formulate strategies to eliminate them.

Pilot study evaluating the effects of an intervention to enhance culturally appropriate hypertension education among healthcare providers in a primary care setting

Background

To improve hypertension care for ethnic minority patients of African descent in the Netherlands, we developed a provider intervention to facilitate the delivery of culturally appropriate hypertension education. This pilot study evaluates how the intervention affected the attitudes and perceived competence of hypertension care providers with regard to culturally appropriate care.

Methods

Pre- and post-intervention questionnaires were used to measure the attitudes, experienced barriers, and self-reported behaviour of healthcare providers with regard to culturally appropriate cardiovascular and general care at three intervention sites (N = 47) and three control sites (N = 35).

Results

Forty-nine participants (60%) completed questionnaires at baseline (T0) and nine months later (T1). At T1, healthcare providers who received the intervention found it more important to consider the patient's culture when delivering care than healthcare providers who did not receive the intervention (p = 0.030). The intervention did not influence experienced barriers and self-reported behaviour with regard to culturally appropriate care delivery.

Conclusion

There is preliminary evidence that the intervention can increase the acceptance of a culturally appropriate approach to hypertension care among hypertension educators in routine primary care.

Migrants and emerging public health issues in a globalized world: threats, risks and challenges, an evidence-based framework

International population mobility is an underlying factor in the emergence of public health threats and risks that must be managed globally. These risks are often related, but not limited, to transmissible pathogens. Mobile populations can link zones of disease emergence to lowprevalence or nonendemic areas through rapid or high-volume international movements, or both. Against this background of human movement, other global processes such as economics, trade, transportation, environment and climate change, as well as civil security influence the health impacts of disease emergence. Concurrently, global information systems, together with regulatory frameworks for disease surveillance and reporting, affect organizational and public awareness of events of potential public health significance. International regulations directed at disease mitigation and control have not kept pace with the growing challenges associated with the volume, speed, diversity, and disparity of modern patterns of human movement. The thesis that human population mobility is itself a major determinant of global public health is supported in this article by review of the published literature from the perspective of determinants of health (such as genetics/biology, behavior, environment, and socioeconomics), population-based disease prevalence differences, existing national and international health policies and regulations, as well as inter-regional shifts in population demographics and health outcomes. This paper highlights some of the emerging threats and risks to public health, identifies gaps in existing frameworks to manage health issues associated with migration, and suggests changes in approach to population mobility, globalization, and public health. The proposed integrated approach includes a broad spectrum of stakeholders ranging from individual health-care providers to policy makers and international organizations that are primarily involved in global health management, or are influenced by global health events.

Differences in vulnerability factors for depressive episodes in African American and European American adolescents

BACKGROUND

Although intervention tailoring could lower the burden of adolescent depression, few studies have examined differences in vulnerability factors between African American and European American youth.

METHODS

We determined and compared the prevalence, relative risk, and population-attributable risk (PAR) of baseline vulnerability factors predicting depressive episodes at 1-year follow-up in a nationally representative sample of African American and European American adolescents.

RESULTS

The leading (highest PAR) vulnerability factors for African American adolescents were demographics, while the top vulnerability factors for European American youth were current depressed affect and low perceived family connectedness. Unique vulnerability factors for African American youth were (1) neither parent finished high school, (2) believing oneself unintelligent, and (3) running away from home. Avoidant problem solving, divorce, poor residential father relationship, sexual relationships, and delinquent behaviors did not predict depressive episodes in African American adolescents but did in European American. Low family and peer connectedness were important common vulnerability factors for both groups.

CONCLUSIONS

Differing patterns of vulnerability suggest that alternative strategies may be better suited to preventing depression among African American youth. A first step may lie in understanding what mediates the effect of low parental educational status on future depression risk.

Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening

BACKGROUND/OBJECTIVE

Brief alcohol counseling is a foremost US prevention priority, but no health-care system has implemented it into routine care. This study evaluated the effectiveness of an electronic clinical reminder for brief alcohol counseling ("reminder"). The specific aims were to (1) determine the prevalence of use of the reminder and (2) evaluate whether use of the reminder was associated with resolution of unhealthy alcohol use at follow-up screening.

METHODS

The reminder was implemented in February 2004 in eight VA clinics where providers routinely used clinical reminders. Patients eligible for this retrospective cohort study screened positive on the AUDIT-C alcohol screening questionnaire (February 2004-April 2006) and had a repeat AUDIT-C during the 1-36 months of follow-up (mean 14.5). Use of the alcohol counseling clinical reminder was measured from secondary electronic data. Resolution of unhealthy alcohol use was defined as screening negative at follow-up with a >/=2-point reduction in AUDIT-C scores. Logistic regression was used to identify adjusted proportions of patients who resolved unhealthy alcohol use among those with and without reminder use.

RESULTS

Among 4,198 participants who screened positive for unhealthy alcohol use, 71% had use of the alcohol counseling clinical reminder documented in their medical records. Adjusted proportions of patients who resolved unhealthy alcohol use were 31% (95% CI 30-33%) and 28% (95% CI 25-30%), respectively, for patients with and without reminder use (p-value = 0.031).

CONCLUSIONS

The brief alcohol counseling clinical reminder was used for a majority of patients with unhealthy alcohol use and associated with a moderate decrease in drinking at follow-up.