Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model

Associations and community health workers: analysis and time trends over ten years of training-action

OBJECTIVE

To analyse the profile of the persons and associations that participated in the course, quantify peer education activities and analyse their evolution.

METHOD

A quantitative study using an analysis of the course records from 2009 to 2018 was designed for this purpose inside mihsalud program designed to promote health amongst persons in vulnerable situations in the city of Valencia (Spain). It offers a yearly training-action course of community health workers (CHW) that is attended by persons who have been proposed by associations. The associations were defined according to their population (immigrant, local or intercultural) and the CHWs according to gender, country of birth, year of course, association and continuity after training. Means and confidence intervals were calculated at 95% and a bivariate analysis was conducted in order to compare the activities that took place in 2009 to 2013 with those of 2014 to 2018. The time trends were analysed by applying linear regression models that included the different years studied as the dependent variable.

RESULTS

201 CHW of 31 nationalities were trained, 81.6% (95% confidence interval [95% CI]: 75.5-86.7] were women. Eighty-two associations participated, 51.2% (95% CI: 39.9-62.4] worked with culturally diverse populations. Participation by associations (p=.017) and CHWs (p=.377) increased in a statistically significant manner over the years. After the course, 35.3% (95% CI: 28.7-42.4] of the CHWs continued to collaborate voluntarily in the associations.

CONCLUSIONS

The results of the CHW training-action course improve over time given that a significant increase in participation by associations and women can be seen, along with a greater number of activities completed during the training. One effect of this is that CHWs are contracted or carry out voluntary activities in the associations.

Drivers of continued implementation of cultural competence in substance use disorder treatment

The purpose of this study was to examine whether the key characteristics of organizational decision makers predicted continued implementation of five different practices that represent organizational cultural competence in one of the largest and most diverse substance use disorder (SUD) treatment systems in the United States. We analyzed data collected from SUD treatment programs at four-time points: 2011 (N = 115), 2013 (N = 111), 2015 (N = 106), and 2017 (N = 94). We conducted five mixed-effect linear regression models, one per each outcome to examine the extent to which program director's transformational leadership and ethnic background (Latino) predicted (1) knowledge of minority community needs; (2) development of resources and linkages to serve minorities; (3) reaching out to minority communities; (4) hiring and retention of staff members from minority backgrounds; and (5) development of policies and procedures to effectively respond to the service needs of minority patients. Results show that two of the five practices continued implementation at same degree (resources and linkages and policies and procedures), one practice increased degree of implementation (knowledge), while two practices reduced degree of implementation (staffing and outreach to communities) over the six-year period. Directorial leadership was positively associated with the continued implementation of all five practices. Latino directors were associated with an increase in knowledge of minority communities, but a decrease in resources and linkages and policies and procedures to serve minorities. On the other hand, interactions showed that leadership among Latino directors increased staffing over time and led to increases in resources and linkages and policies and procedures overtime. Overall, continued implementation of culturally responsive practices was uneven in the SUD treatment system studied. But program directors' transformational leadership and ethnic background played a critical role in increasing the implementation of key practices over time. Findings have implications for developing and testing culturally grounded leadership interventions for program directors to ensure the continued and increased implementation of practices that are necessary to improve standards of care in minority health.

Providing Care for Children in Immigrant Families

Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non-US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.

Barriers to mammography screening among racial and ethnic minority women

RATIONALE

Breast cancer is the second leading cause of cancer death among women. Disparities in breast cancer mortality rates adversely affect racial/ethnic minority women. Mammography screening is the most effective early detection method and means of reducing mortality rates. Yet, barriers prevent racial/ethnic minority women from participating in regular screening.

OBJECTIVE

This review aimed to summarize self-reported barriers to mammography screening in racial/ethnic minority women in studies using open-ended assessments and closed-ended assessments.

METHOD

Literature searches were conducted in two databases, PsycINFO and PubMed. Barriers were detailed in full by barrier type (psychological/knowledge-related, logistical, cultural/immigration-related, and social/interpersonal) and summarized briefly by race/ethnicity (African American/Black, Asian/Pacific Islander, Hispanic, American Indian/Native American, and Middle Eastern).

RESULTS

Twenty-two open-ended and six closed-ended studies were identified as eligible for this review. Overall, racial/ethnic minority women identified common logistical and psychological/knowledge-related barriers. Additionally, women reported cultural/immigration-related and social/interpersonal barriers that were closely tied to their racial/ethnic identities.

CONCLUSIONS

It was concluded that cultural/immigration-related barriers may be the only barrier type that is unique to racial/ethnic minority women. Thus, designing studies of barriers around race and ethnicity is not always appropriate, and other demographic factors are sometimes a more important focus. The variability in 'barrier' definitions, how data were collected and reported, and the appropriateness of closed-ended measures were also examined. This literature may benefit from detailed and strategically designed studies that allow more clear-cut conclusions and better comparison across studies as well as improving closed-ended measures by incorporating insights from investigations using open-ended inquiry.

Communication with Diverse Patients: Addressing Culture and Language

Effective communication is key when providing quality health care. The dynamics of communication within the health care team and with the patient and family can be challenging. These challenges stem from the sharing of complex information, highly emotional topics, and health literacy barriers. Linguistic and cultural barriers can further aggravate these challenges. This section provides an overview of linguistic and cultural challenges related to patient-provider communication, strategies for effective communication with patients with limited English Proficiency via the use of interpreter services, and tips for how to teach these skills to health care providers.

Evaluating the Training of Chinese-Speaking Community Health Workers to Implement a Small-Group Intervention Promoting Mammography

This study evaluated the training of Chinese American Community Health Workers (CHWs) to implement a small-group mammography video and discussion program as part of a randomized controlled trial that had the goal to increase adherence to mammography screening guidelines among Chinese American women. A total of 26 Chinese American CHWs in the metropolitan Washington DC area, Southern California, and New York City participated in a 4-h training workshop and completed surveys before and after the workshop to assess their knowledge regarding mammography screening guidelines and human subjects protection rules. The results showed significantly increased knowledge of mammography screening guidelines and human subjects protection rules (both p < 0.01) after the training. CHWs were also trained to lead a discussion of the video, including screening benefits and misconceptions. Forty-three audio recordings of discussions led by 13 active CHWs were transcribed and qualitatively analyzed to assess implementation fidelity. Ten out of 13 active CHWs fully addressed about 3 of the 5 benefit items, and 11 out of 13 CHWs fully addressed more than 5 of the 9 misconception items. Chinese CHWs can be trained to implement research-based intervention programs. However, a one-time training resulted in moderate adherence to the discussion protocol. Ongoing or repeat trainings throughout the intervention period may be needed to enhance implementation fidelity.

Culturally competent healthcare - A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision

Background

Culturally and linguistically diverse patients access healthcare services less than the host populations and are confronted with different barriers such as language barriers, legal restrictions or differences in health beliefs. In order to reduce these disparities, the promotion of cultural competence in healthcare organizations has been a political goal. This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for culturally and linguistically diverse patients within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

Methods and findings

A systematic literature search was carried out using three databases (Pubmed, PsycINFO and Web of Science) to identify studies which have implemented and evaluated cultural competence interventions in healthcare facilities. PICO criteria were adapted to formulate the research question and to systematically choose relevant search terms. Sixty-seven studies implementing culturally competent healthcare interventions were included in the final synthesis. Identified strategies and components of culturally competent healthcare extracted from these studies were clustered into twenty categories, which were organized in four groups: Components of culturally competent healthcare–Individual level; Components of culturally competent healthcare–Organizational level; Strategies to implement culturally competent healthcare and Strategies to provide access to culturally competent healthcare. A model integrating the results is proposed. The overall effects on patient outcomes and utilization rates of identified components or strategies were positive but often small or not significant. Qualitative data suggest that components and strategies of culturally competent healthcare were appreciated by patients and providers.

Conclusion

This scoping review used a bottom-up approach to identify components and strategies of culturally competent healthcare interventions and synthesized the results in a model of culturally competent healthcare provision. Reported effects of single components or strategies are limited because most studies implemented a combination of different components and strategies simultaneously.

"Living happily despite having an illness": Perceptions of healthy aging among Korean American, Vietnamese American, and Latino older adults

BACKGROUND/OBJECTIVE

The growingly diverse aging population presents a challenge for the geriatric workforce, particularly its capacity to effectively respond to the sociocultural and linguistic needs of ethnic minority older adults. Informed by research on the importance of culturally-competent care in reducing racial and ethnic health disparities, this study sought to understand the meaning of healthy aging from the perspectives of Korean American, Vietnamese American, and Latino older adults.

METHODS

Interviews were conducted with 30 participants recruited from community-based organizations in Southern California.

RESULTS

Several dimensions emerged in the participants' understanding of healthy aging: (1) having good physical and mental health (2) optimism and acceptance; (3) social connectedness; (4) taking charge of one's health; and (5) independence and self-worth.

CONCLUSIONS

Results could inform the development of a culturally-responsive geriatric healthcare system that takes into account older adults' beliefs, preferences, and needs to promote successful aging.

Social Networks for Human Papillomavirus Vaccine Advice Among African American Parents

PURPOSE

Despite that human papillomavirus (HPV) vaccination could prevent ∼90% of HPV-associated cancers, only 65.5% of American adolescents initiate vaccination. African Americans have the highest prevalence of morbidity and mortality from HPV-associated cancers. Mounting evidence suggests that advice from social contacts is associated with vaccine acceptance. The present study examines the associations of social processes with HPV vaccine refusal among African American parents.

METHODS

A cross-sectional survey was conducted among African American parents of children aged 10-12 years before a health-care visit at which HPV vaccine was offered by the health-care provider. Data from the 353 parents who named at least one social contact who advised them about vaccines were included in these analyses.

RESULTS

Only 54.4% of the participants consented to HPV vaccination for their children. On average, parents had 2 to 3 social contacts who provided vaccine advice. Vaccine advice networks were generally dense, family-centric, and homophilous. Slightly over 80% of all parents trusted family members and friends for vaccine advice "some" or "a lot." Controlling for sociodemographic characteristics and reason for the health-care visit, perceived high exposure to anti-HPV vaccine viewpoints and low exposure to pro-HPV vaccine viewpoints were both associated with HPV vaccine refusal (adjusted odds ratio = 1.5, 95% confidence interval = 1.01, 2.3, and adjusted odds ratio = 1.7, 95% confidence interval = 1.2, 2.6, respectively).

CONCLUSIONS

Social processes may be associated with HPV vaccine refusal among African American parents. Interventions designed to educate African American parents about HPV vaccine to increase uptake should consider leveraging vaccine advice networks for greater impact.

Perspectives on Training Needs for Geriatric Mental Health Providers: Preparing to Serve a Diverse Older Adult Population

An increasingly diverse population of older adults requires a diverse workforce trained to address the problem of differential healthcare access and quality of care. This article describes specific areas of training focused on addressing health disparities based on ethnic differences. Culturally competent care by mental health providers, innovative models of mental health service delivery such as collaborative care, and expansion of the mental health workforce through integration of lay health workers into professional healthcare teams, offer potential solutions and require training. Cultural competency, defined as respect and responsiveness to diverse older adults' health beliefs, should be an integral part of clinical training in mental health. Clinicians can be trained in avoidance of stereotyping, communication and development of attitudes that convey cultural humility when caring for diverse older adults. Additionally, mental health clinicians can benefit from inter-professional education that moves beyond professional silos to facilitate learning about working collaboratively in interdisciplinary, team-based models of mental health care. Finally, familiarity with how lay health workers can be integrated into professional teams, and training to work and supervise them are needed. A growing and diversifying population of older adults and the emergence of innovative models of healthcare delivery present opportunities to alleviate mental health disparities that will require relevant training for the mental health workforce.

Ethnic discordance: Why do some patients prefer to be treated by physicians from other ethnic groups?

Current literature on patient-physician concordance emphasizes its advantages. Racial, ethnic, cultural and linguistic concordance was found to impact patient-physician communication positively and to lead to improved healthcare quality and outcomes. Patients' preference for ethnic discordance, on the other hand, appears anomalous and has barely been studied. The present research sought to evaluate the rates of patients from the Jewish majority and the Arab minority populations in Israel who prefer patient-physician ethnic discordance, and to examine the reasons for this preference. A mixed method methodology was employed: a survey (n = 760; 505 Jews, 255 Arabs), as well an exploratory qualitative study based on in-depth interviews with 38 Jewish and Arab patients in Israel. The survey's findings indicate that Arabs are more likely to prefer to be treated by a Jewish physician than are Jews to prefer an Arab physician (family physician - 4.3% vs. 0.4%, p < .0001; surgeon - 5.9% vs. 0.8%, p < .0001). The difference is age-dependent: young Arabs are more likely than older ones to prefer a Jewish physician. The reasons for Arabs' preference for a Jewish physician are fear of a breach of confidentiality, and internalized racism. The reasons for Jews' preference for an Arab physician are the disposition and professionalism attributed to the latter, which are perceived to stem from their need, as a minority population, to excel and to prove themselves. Despite the emphasis placed in scholarship and clinical practice on the importance of cultural and linguistic competency in healthcare, a preference for ethnic discordance should also be taken into account, especially regarding patients from minority collectivist populations.

Cultural Considerations for Psychologists in Primary Care

Many health concerns in the United States (e.g., diabetes) are routinely managed in primary care settings. Regardless of the medical condition, patients' health is directly influenced by factors such as healthcare providers and cultural background. Training related to how behaviors influence health, coupled with training on how cultural diversity intersects with mental health, allows psychologists to have the relevant expertise to assist in the development of primary care behavioral health interventions. However, many psychologists in primary care struggle with how to integrate a culture-centered paradigm into their roles as behavioral health providers. This paper provides an introduction on how three culture-centered concepts (providers' cultural sensitivity, patient-provider cultural congruency, and patients' health literacy) can be applied in primary care using the Five A's Organizational Construct and a model of cultural competence. In addition, the paper includes a section on integration of cultural considerations into consultation and training and concludes with a discussion of how the three culture-centered concepts have implications for health equity.

Community members trusted by African American parents for vaccine advice

Exposure to pro-vaccination messages from nonmedical peers and others perceived to share a similar value system for society (referred to as worldview outlook) improves vaccination attitudes. Nonetheless, a minority of African American parents have friends and family members who provide them with vaccine advice. The aims of the current study were to identify the presumed worldview outlook of eight types of community figures as perceived by African American parents, and determine parents' trust in these figures for vaccine advice, and whether trust varied according to the figures' racial concordance. A cross-sectional survey was administered to 110 African American parents in 2015. Parents perceived the community figures to represent a spectrum of worldview outlooks. Although levels of trust in the community figures differed overall (p < .001), it was high in the school nurse, pediatrician, mother, father, disease survivor, and vaccine scientist. All trusted figures except the father were perceived to hold a communitarian outlook. Parents shown race-concordant figures had higher levels of trust in them than those who were shown race-discordant equivalents (p < .01). These findings suggest that vaccination campaigns geared toward African American parents may be strengthened by including other nonmedical, African American spokespersons who convey their community contributions in messages.

Organizational characteristics associated with the provision of cultural competency training in home and hospice care agencies

BACKGROUND

Despite the increasing interest in community-based health care, little information exists on cultural competency training (CCT) and its predictors in this setting.

PURPOSE

We examined the associations between six organizational characteristics and the provision of CCT in home health care and hospice agencies.

METHODOLOGY

We used cross-sectional data from the agency component of the 2007 National Home and Hospice Care Survey. The CCT provision composite was composed of three items: whether the agency provides mandatory cultural training to understand cultural differences/beliefs that may affect delivery of services to (a) all administrators, clerical, and management staff; (b) all direct service providers; and (c) all volunteers. Organizational characteristics were volume, ownership status, chain membership, teaching status, Joint Commission accreditation status, and formal contracts.

PRINCIPAL FINDINGS

The weighted sample (n = 14,469) had a mean CCT provision score of 1.75 (range = 0-3). Our ordinal logistic regression model showed that Joint Commission accreditation increased CCT provision odds in the home health (odds ratio [OR] = 2.07, 95% confidence interval [CI] [1.01, 4.24]) and hospice (OR = 4.40, 95% CI [2.07, 9.38]) settings. Teaching status increased CCT provision odds (OR = 2.71, 95% CI [1.19, 6.17]) in the home health setting. Formal contracts increased CCT provision odds (OR = 4.03, 95% CI [1.80, 9.00]), whereas not-for-profit ownership decreased CCT provision odds (OR = 0.19; 95% CI [0.07, 0.50]) in the hospice setting.

PRACTICE IMPLICATIONS

Home health care and hospice agencies need to increase their CCT practices to overcome health disparities in an increasingly diverse and aging population.

Improving End-of-Life Care through Community-Based Grassroots Collaboration: Development of the Chinese-American Coalition for Compassionate Care

As a volunteer-formed, community-based organization devoted to improving the quality of end-of-life care for Chinese Americans, the new Chinese-American Coalition for Compassionate Care (CACCC) is a unique and promising venture. This article has several aims: 1) to describe the history and development of the recently founded CACCC; 2) to introduce and critically evaluate one of CACCC's first public programs, a volunteer and caregiver training on end-of-life care, which prompted subsequent programs and activities; 3) to report on CACCC's current projects and short- and long-term goals; and 4) to discuss the implications for other similar community-based organizations devoted to the health and quality of life of a targeted population.

The "Waze" of Inequity Reduction Frameworks for Organizations: a Scoping Review

BACKGROUND

Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks.

OBJECTIVE

To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable.

STUDY DESIGN

Fourteen inequity frameworks from scoping literature review 2000-2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time.

PARTICIPANTS

We conducted member check interviews with framework authors to verify our assessments.

KEY RESULTS

Frameworks stressed assessing the organization's outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks.

CONCLUSIONS

Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions.

The challenge of cultural competence in the workplace: perspectives of healthcare providers

Background

Cross-cultural educational initiatives for professionals are now commonplace across a variety of sectors including health care. A growing number of studies have attempted to explore the utility of such initiatives on workplace behaviors and client outcomes. Yet few studies have explored how professionals perceive cross-cultural educational models (e.g., cultural awareness, cultural competence) and the extent to which they (and their organizations) execute the principles in practice. In response, this study aimed to explore the general perspectives of health care professionals on culturally competent care, their experiences working with multi-cultural patients, their own levels of cultural competence and the extent to which they believe their workplaces address cross-cultural challenges.

Methods

The perspectives and experiences of a sample of 56 health care professionals across several health care systems from a Mid-Western state in the United States were sourced via a 19-item questionnaire. The questionnaire comprised both open-ended questions and multiple choice items. Percentages across participant responses were calculated for multiple choice items. A thematic analysis of open-ended responses was undertaken to identify dominant themes.

Results

Participants largely expressed confidence in their ability to meet the needs of multi-cultural clientele despite almost half the sample not having undergone formal cross-cultural training. The majority of the sample appeared to view cross-cultural education from a ‘cultural awareness’ perspective - effective cross-cultural care was often defined in terms of possessing useful cultural knowledge (e.g., norms and customs) and facilitating communication (the use of interpreters); in other words, from an immediate practical standpoint. The principles of systemic cross-cultural approaches (e.g., cultural competence, cultural safety) such as a recognition of racism, power imbalances, entrenched majority culture biases and the need for self-reflexivity (awareness of one’s own prejudices) were scarcely acknowledged by study participants.

Conclusions

Findings indicate a need for interventions that acknowledge the value of cultural awareness-based approaches, while also exploring the utility of more comprehensive cultural competence and safety approaches.

Cultural awareness workshops: limitations and practical consequences

Cultural awareness training for health professionals is now commonplace across a variety of sectors. Its popularity has spawned several alternatives (i.e., cultural competence, cultural safety, cultural humility, cultural intelligence) and overlapping derivatives (diversity training, anti-racism training, micro-aggression training). The ever-increasing reach of cultural awareness initiatives in health settings has generally been well intentioned - to improve cross-cultural clinical encounters and patient outcomes with the broader expectation of reducing health disparities. Yet the capacity of cultural awareness training to accomplish or even impact such outcomes is seldom comprehensively scrutinized. In response, this paper applies a much needed critical lens to cultural awareness training and its derivatives by examining their underpinning philosophies, assumptions and most importantly, verification of their effectiveness. The paper finds cultural awareness approaches to be over-generalizing, simplistic and impractical. They may even induce unintended negative consequences. Decades of research point to their failure to realize meaningful outcomes in health care settings and beyond. Broader expectations of their capacity to reduce health disparities are almost certainly unachievable. Alternative suggestions for improving cross-cultural health care interactions and research are discussed within.

Cultural Immersion in the Education of Healthcare Professionals: A Systematic Review

PURPOSE

With the ever-changing cultural makeup of society, the ability to deliver culturally appropriate healthcare is essential. One educational method aimed at increasing cultural knowledge and sensitivity in the education of healthcare professionals is cultural immersion. Cultural immersion creates opportunity for transformational learning through direct interaction with culturally diverse populations. The purpose of this systematic review is to examine the qualitative effects of cultural immersion experiences on graduate-level healthcare professional students.

METHODS

A search of the CINAHL and ERIC databases was performed utilizing search terms including cultural immersion, cultural sensitivity, educational outcomes, and healthcare professionals limited to publication within the last 10 years. The articles were screened according to title, abstract, and full-text following application of inclusion/exclusion criteria. Themes identified within each article were collected and categorized, using qualitative methodology, into five overarching domains to assess the educational experiences. Studies were scored for quality using the qualitative portion of the McGill Mixed Methods Appraisal Tool - 2011.

RESULTS

Nine studies incorporating a total of 94 participants with experiences in 14 different culturally diverse environments revealing 47 individually identified themes were included in the review. Results indicated that all cultural immersion experiences stimulated increased cultural awareness and sensitivity.

DISCUSSION

Cultural immersion experiences produced a positive, multi-domain effect on cultural learning in students of the health professionals. Results support a basis for implementation of cultural immersion experiences into the education of healthcare professionals with the goal of increasing cultural sensitivity.

A Multidimensional Developmental Approach to Understanding Intragroup Marginalization and Mental Health Among Adolescents and Emerging Adults of Mexican Descent

The present study investigates whether different forms of intragroup marginalization (IM) are associated with depressive symptoms, suicide risk, life satisfaction, and self-esteem for Mexican descent adolescents and emerging adults.Furthermore, we will investigate whether these associations vary by developmental period. The sample included 722 Mexican descent adolescents and emerging adults (age range = 14-25 years, M = 19.69 years, SD = 1.75 years; 65.9% women). Higher IM-Family was related to higher depressive symptoms, suicide risk, and lower life satisfaction and self-esteem. Higher IM-Friends was related to higher depressive symptoms and suicide risk, and lower life satisfaction and self-esteem. Developmental period moderated the relationship between IM-Friends on depressive symptoms, suicide risk, and self-esteem. In addition, it moderated the relationship between IM-Ethnic Group on suicide risk.The results of this study demonstrate that the various IM dimensions are differentially associated with mental health outcomes for Latinx adolescents and emerging adults. Furthermore, these associations sometimes vary depending on the developmental period membership.

Recommendations for a culturally-responsive mindfulness-based intervention for African Americans

BACKGROUND

African Americans are at increased risk for stress-related disparities. Mindfulness-based interventions are effective in reducing adverse outcomes; yet, racial/ethnic minorities are underrepresented in these interventions. Also, the development of culturally-responsive interventions has been mostly non-existent.

MATERIALS AND METHODS

Focus group and interview data were acquired following a four-week mindfulness intervention with African American women.

RESULTS

Using Brigg's (2011) mental health utilization model to guide analysis, several recommended culturally-responsive modifications emerged. Recommended modifications internal to the intervention included using African American facilitators, incorporating cultural values, using culturally-familiar terminology, and providing cultural resources. Suggested modifications to the intervention's external factors included offering the intervention within culturally-familiar settings. Individual-level factors to address were religious concerns, perceived benefits, and holistic health goals.

CONCLUSIONS

Themes were used to propose a model toward the creation of a culturally-responsive mindfulness-based interventions to guide culturally-relevant treatment modifications and improve underserved communities' engagement in these interventions.

Prospective Predictors of Multiple Sexual Partners Among African American Men Who Have Sex with Men

Studies show that having sex with multiple partners increases the risk of acquiring and transmitting sexually transmitted diseases, including HIV. The present article reports prospective predictors of having multiple sexual partners among 505 African American men in Philadelphia who have sex with men (MSM) who participated in an intervention trial and attended a 6-month follow-up. Participants completed audio computer-assisted surveys of demographics, sexual behavior, and Reasoned Action Approach and Social Cognitive Theory mediators concerning multiple partners. We analyzed the incidence of self-reported multiple partners at the 6-month follow-up, controlling for treatment condition and baseline levels of the theoretical variables. The odds of having multiple partners decreased with increasing age (p < .03). Participants who said they were HIV positive had lower odds of having multiple partners (p < .009). The more pride participants reported in their identities as black or African American men, the lower the odds that they reported having multiple partners (p < .02). Adverse outcome expectancies accruing to multiple partners fully mediated the effect of black pride and partially mediated the effects of age on the odds of having multiple partners. Modifiable factors such as perceived negative outcome expectancies regarding having multiple sex partners should be addressed in designing interventions and prevention programs with the goal of decreasing the number of sexual partners among African American MSM.

Cultural trauma and epigenetic inheritance

The question of whether and how the effects of cultural trauma can be transmitted intergenerationally from parents to offspring, or even to later generations, has evoked interest and controversy in academic and popular forums. Recent methodological advances have spurred investigations of potential epigenetic mechanisms for this inheritance, representing an exciting area of emergent research. Epigenetics has been described as the means through which environmental influences “get under the skin,” directing transcriptional activity and influencing the expression or suppression of genes. Over the past decade, this complex environment–biology interface has shown increasing promise as a potential pathway for the intergenerational transmission of the effects of trauma. This article reviews challenges facing research on cultural trauma, biological findings in trauma and posttraumatic stress disorder, and putative epigenetic mechanisms for transmission of trauma effects, including through social, intrauterine, and gametic pathways. Implications for transmission of cultural trauma effects are discussed, focused on the relevance of cultural narratives and the possibilities of resilience and adaptivity.

Implementation and impact of indigenous health curricula: a systematic review

CONTEXT

The effectiveness of cultural competency education in improving health practitioner proficiency and addressing health inequities for minoritised patient groups is uncertain. Identification of institutional factors that shape or constrain development of indigenous health curricula may provide insights into the impact of these factors on the broader cultural competency curricula.

METHODS

We undertook a systematic review using actor-network theory to inform our interpretive synthesis of studies that reported indigenous health curricula evaluated within medical, nursing and allied health education. We searched the MEDLINE, OVID Nursing, Educational Resources Information Center (ERIC), PsycINFO, EMBASE, Web of Science and PubMed databases to December 2017 using exploded MeSH terms 'indigenous' and 'medical education' and 'educational professional' and 'health professional education'. We included studies involving undergraduate or postgraduate medical, nursing or allied health students or practitioners. Studies were eligible if they documented indigenous health learning outcomes, pedagogical practices and student evaluations.

RESULTS

Twenty-three studies were eligible for the review. In an interpretive synthesis informed by actor-network theory, three themes emerged from the data: indigenous health as an emerging curriculum (drivers of institutional change, increasing indigenous capacity and leadership, and addressing deficit discourse); institutional resource allocation to indigenous health curricula (placement within the core curriculum, time allocation, and resources constraining pedagogy), and impact of the curriculum on learners (acceptability of the curriculum, learner knowledge, and learner behaviour).

CONCLUSIONS

Systemic barriers acting on and within educational networks have limited the developmental capacity of indigenous health curricula, supported and sustained hidden curricula, and led to insufficient institutional investment to support a comprehensive curriculum. Future research in health professional education should explore these political and network intermediaries acting on cultural competence curricula and how they can be overcome to achieve cultural competency learning outcomes.

The Importance of Culture in Addressing Domestic Violence for First Nation's Women

Indigenous women in Canada face a range of health and social issues including domestic violence. Indigenous women (First Nations, Inuit and Métis) are six times more likely to be killed than non-Aboriginal women (Homicide in Canada, 2014; Miladinovic and Mulligan, 2015). Aboriginal women are 2.5 times more likely to be victims of violence than non-Aboriginal women (Robertson, 2010). These and other statistics highlight a significant difference in the level of violence experienced by Indigenous women to that experienced by women in the mainstream population in Canada. The historical impacts of colonization and forced assimilation are viewed as the main social determinant of health for aboriginal people in Canada, as they led to intergenerational trauma, with communities struggling today against discrimination, stigma, poverty and social exclusion. Most disturbing and damaging are the outcomes of domestic violence, mental health and addiction issues (Prussing, 2014). First Nation's women who want to leave a violent situation have limited access to helping services, as most are located in large cities and towns, far from remote reserves where many of the women live. Services were originally designed by and for the mainstream population. First Nation's women who manage to access these programs often find staff with limited cultural competence and program supports that have little cultural safety or relevance for them. Indigenous culture is defined in various levels of legislation as having a set of specific rights based on their historical ties to a particular region, with cultural or historical distinctiveness from the mainstream and other populations (Indigenous Peoples at the UN, 2014). In Canada, indigenous cultural beliefs are closely tied to belief in a creator, ancestors and the natural world, influencing their spirituality and their political perspectives (Waldram et al., 2006). Cultural safety, a concept that emerged in the 1980's in New Zealand, is viewed as an environment that is spiritually, socially, emotionally and physically safe for people; where cultural identity is recognized and valued through shared respect, meaning, knowledge and the experience of learning together. This paper will explore current evidence-based literature to determine if there is empirical evidence to support program policies and practices that reflect culturally safe, competent and relevant domestic violence services to address the cultural needs of Indigenous women in Canada.

US ethnic group differences in self-management in the 2nd diabetes attitudes, wishes and needs (DAWN2) study

AIMS

Understanding the relationship between ethnicity and self-management is important due to disparities in healthcare access, utilization, and outcomes among adults with type 2 diabetes from different ethnic groups in the US.

METHODS

Self-reports of self-management and interest in improving self-management from US people with diabetes (PWD) in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) study, a multinational, multi-stakeholder survey, were analyzed, including 447 non-Hispanic White, 241 African American, 194 Hispanic American, and 173 Chinese American PWD (>18 years).

RESULTS

Overall, self-management behavior was highest for medication taking and lowest for physical activity. Non-Hispanic Whites had lowest physical activity and highest adherence to insulin therapy. Chinese Americans had lowest foot care and highest healthy eating. Overall, interest was highest for improving healthy eating and physical activity. Chinese Americans and Hispanic Americans were more interested than non-Hispanic Whites in improving most self-management behaviors. Chinese Americans were more interested than African Americans in improving most self-management behaviors. Healthcare providers telling PWD that their A1c needs improvement was associated with lower self-rated glucose control, which was associated with higher PWD interest in improving self-management behaviors.

CONCLUSIONS

Diabetes care providers should use patient-centered approaches and consider ethnicity in tailoring self-management support.

Towards a culturally competent health professional: a South African case study

BACKGROUND

South Africa (SA) has a growing multilingual and multicultural population of approximately 55 million people, and faces service delivery challenges due to a shortage in skilled health professionals. Many health care facilities still depict distinct racial and ethnic characteristics that date back to the apartheid era, and there are reports of racial intolerance or preferential treatment at some facilities. There is limited literature in South Africa on cultural competence or on how to train health professionals to provide culturally competent care. This paper describes a study conducted to gain a better understanding of final year medical students' perceptions regarding concepts related to cultural and linguistic competence in the SA healthcare setting.

METHODS

An exploratory, cross-sectional, analytical study used a questionnaire to collect data from final year students at the medical school.

RESULTS

The demographic profile indicated considerable diversity in the respondents for languages spoken, ethnicity and religion. Responses indicated a level of cultural awareness and, according to the Cross Framework, a position of cultural pre-competence. This position was supported by the majority expressing high levels of agreement with the items deemed to indicate responsiveness: a desire for cultural competence to be promoted in the medical curriculum and for professional development to improve delivery of services and support to linguistically and culturally diverse groups. No significant association was found when analysing the latter item against demographic grouping variables. However, although not significant, a diminishing trend emerged in the rankings of monolingualism, bilingualism and multilingualism, suggesting that the ability to speak more than one language could possibly be a facilitating factor in acquiring cultural competence.

CONCLUSIONS

In response, it is recommended that specific learning objectives be included in the medical curriculum. Understanding of concepts related to both individual and institutional cultural competence would improve insights into their relevance in responding to the challenges related to culture in SA healthcare. Further research in teaching cultural competence is recommended. In order to respond to local needs, this should include research at a community level to analyse patients' perspectives and satisfaction with the cultural competence of healthcare providers and organisations serving the SA public.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Global Health Education and Advocacy: Using BMJ Case Reports to Tackle the Social Determinants of Health

Since 2013, BMJ Case Reports (http://casereports.bmj.com/) has published over 70 global health case reports from five continents, written by doctors, nurses, students, and allied health professionals. These cases, a burgeoning repository of evidence of how real patients are affected by disease, trauma, violence, sexual assault, conflict, migration, adverse living and working conditions, and poor access to health care, discuss, in addition to clinicopathological findings, the global health problems affecting each patient. The global health problem analysis examines the problems of individual patients, critically appraises the literature, and describes actual and potential solutions for the patient, the local community, and patients affected by similar issues across the world. At present global health literature and learning materials lack a patient focus and real-life context in the analysis of global health problems. BMJ Case Reports global health case reports are a unique and important tool to learn about and advocate for change in the social, political, cultural, and financial determinants of health as they affect real patients. This growing evidence base brings together clinicians, local service providers, policy makers, and government and non-governmental institutions to effect real change in patients' lives toward improving health. Each global health case report is an excellent resource for learning, and together, these case reports provide essential reading for anyone embarking on a career in global health, and writing their own case report. The online course (http://casereports.bmj.com/site/misc/GHMA_Mar_2017.pptx) at BMJ Case Reports uses these cases and is free to access.

Health workforce cultural competency interventions: a systematic scoping review

Background

Addressing health workforce cultural competence is a common approach to improving health service quality for culturally and ethnically diverse groups. Research evidence in this area is primarily focused on cultural competency training and its effects on practitioners’ knowledge, attitudes, skills and behaviour. While improvements in measures of healthcare practitioner cultural competency and other healthcare outcomes have been reported, there are concerns around evidence strength and quality. This scoping review reports on the intervention strategies, outcomes, and measures of included studies with the purpose of informing the implementation and evaluation of future interventions to improve health workforce cultural competence.

Methods

This systematic scoping review was completed as part of a larger systematic literature search conducted on cultural competence intervention evaluations in health care in Canada, the United States, Australia and New Zealand published from 2006 to 2015. Overall, 64 studies on cultural competency interventions were found, with 16 aimed directly at the health workforce.

Results

There was significant heterogeneity in workforce intervention strategies, measures and outcomes reported across studies making comparisons of intervention effects difficult. The two main workforce intervention strategies identified were cultural competency training and other professional development interventions including other training and mentoring. Positive outcomes were commonly reported for improved practitioner knowledge (9/16), skills (7/16), and attitudes/beliefs (5/16). Although health care (6/16) and health (2/16) outcomes were reported in some studies there was very limited evidence of positive intervention impacts. Only four studies utilised existing validated measurement tools to assess intervention outcomes.

Conclusion

Training and development of the health workforce remain a principle strategy towards the goal of improved cultural competence in health services and systems. Diverse approaches are available to increase health workforce cultural competence. However, the effects of interventions beyond practitioner knowledge and attitudes remains unclear. Assessment of practitioner behavioural outcomes as well as measures of intervention impact on healthcare and health outcomes are needed to build a stronger evidence base.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3001-5) contains supplementary material, which is available to authorized users.

Factor Structure of the Cultural Competence Items in the National Home and Hospice Care Survey

BACKGROUND

There is a need for validated measures of cultural competency practices in home health and hospice care (HHHC).

OBJECTIVE

To establish the factor structure of the cultural competency items included in the agency-component of the 2007 public-use National Home and Hospice Care Survey file.

DATA SOURCE

We used weighted survey data from 1036 HHHC agencies.

RESEARCH DESIGN AND PARTICIPANTS

We used exploratory factor analyses to identify a preliminary factor structure, and then performed confirmatory factor analysis to provide further support for identified factor structure.

MEASURES

We examined 9 cultural competency items.

RESULTS

Exploratory factor analyses suggested an interpretable 2-factor solution: (1) the provision of mandatory cultural competency training; and (2) the provision of cultural competency communication practices. Each factor consisted of 3 items. The remaining 3 items did not load well on these factors. A similar, but more restrictive, confirmatory factor analysis model without cross-loadings supported the 2-factor model: (Equation is included in full-text article.)=9.50, P=0.30, root mean square error of approximation (RMSEA)=0.01, comparative fit index (CFI)=0.99, Tucker-Lewis Index (TLI)=0.99.

CONCLUSIONS

Two constructs with 3 items each appeared to be internally valid measures of cultural competency in this nationally representative survey of HHHC agencies: cultural competency training and cultural competency communication practices. These measures could be used by HHHC managers in quality improvement efforts and by policy makers in monitoring cultural competency practices.

A multi-group path analysis of the relationship between perceived racial discrimination and self-rated stress: how does it vary across racial/ethnic groups?

OBJECTIVE

The objective of this study was to answer three questions: (1) Is perceived discrimination adversely related to self-rated stress via the social capital and health care system distrust pathways? (2) Does the relationship between perceived discrimination and self-rated stress vary across race/ethnicity groups? and (3) Do the two pathways differ by one's race/ethnicity background?

DESIGN

Using the Philadelphia Health Management Corporation's Southeastern Pennsylvania Household Survey, we classified 9831 respondents into 4 race/ethnicity groups: non-Hispanic White (n = 6621), non-Hispanic Black (n = 2359), Hispanic (n = 505), and non-Hispanic other races (n = 346). Structural equation modeling was employed to simultaneously estimate five sets of equations, including the confirmatory factor analysis for both social capital and health care distrust and both direct and indirect effects from perceived discrimination to self-rated stress.

RESULTS

The key findings drawn from the analysis include the following: (1) in general, people who experienced racial discrimination have higher distrust and weaker social capital than those without perceived discrimination and both distrust and social capital are ultimately related to self-rated stress. (2) The direct relationship between perceived discrimination and self-rated stress is found for all race/ethnicity groups (except non-Hispanic other races) and it does not vary across groups. (3) The two pathways can be applied to non-Hispanic White and Black, but for Hispanic and non-Hispanic other races, we found little evidence for the social capital pathway.

CONCLUSIONS

For non-Hispanic White, non-Hispanic Black, and Hispanic, perceived discrimination is negatively related to self-rated stress. This finding highlights the importance of reducing interpersonal discriminatory behavior even for non-Hispanic White. The health care system distrust pathway can be used to address the racial health disparity in stress as it holds true for all four race/ethnicity groups. On the other hand, the social capital pathway seems to better help non-Hispanic White and Black to mediate the adverse effect of perceived discrimination on stress.

Sociodemographic Predictors of Missed Appointments Among Patients With Cleft Lip and Palate

Objective:

To identify disparities in compliance of and care for patients with cleft lip and/or palate (CL/P) by determining the impact of sociodemographic variables on the rate of missed appointments and Child Protective Services (CPS) involvement.

Design:

A retrospective, noninterventional quality assessment and quality improvement study were designed.

Setting:

This institutional study was performed at the University of Michigan in Ann Arbor, Michigan.

Patients:

All patients born between January 1, 2011, and December 31, 2014, who underwent surgical CL/P repair, excluding those with fewer than 5 appointments (n = 178).

Main Outcome Measure:

The rate of missed appointments, calculated as the total number of no-show appointments divided by the total number of scheduled appointments. All appointments from CL/P diagnosis to data collection were considered, including those outside of plastic surgery.

Results:

The average patient was 4.5 years of age and had 49 total scheduled appointments. The overall rate of missed appointments was 9.6%, with 66.8% of patients missing at least 1 scheduled visit. Patients who were black ( P = .04), not affiliated with a religion ( P = .01), Medicaid users ( P = .01), from an unstable social background ( P = .01), or received need-based financial assistance ( P = .00) were significantly more likely to miss appointments. Child Protective Services was involved with 3.9% of patients.

Conclusions:

Disparities exist in attendance rates among patients with CL/P, and at-risk patient populations have been identified. The allocation of cleft care resources must be efficiently planned in order to enhance the quality of care for at-risk individuals.

Implementation and Evaluation of a Recurring Interdisciplinary Community Health Fair in a Remote U.S.-Mexico Border Community

The purpose of this project was to design, implement, and assess a recurring interdisciplinary community health fair in an underserved border town. University of California San Diego (UCSD) medical and pharmacy students, under faculty supervision, worked alongside community partners in Calexico, California to implement a health fair two miles from the U.S.-Mexico border. Demographic and screening data were described from 293 participants from 2014 to 2016. Over 90% (269/293) listed Mexico as their country of birth, 82.9% (243/293) were monolingual Spanish speakers, 75.4% (221/293) had an annual household income of ≤ $20,000, and 58.7% (172/293) described their health as fair or poor. Screening revealed 91.1% (265/291) were overweight or obese, 37.8% (109/288) had hypertension, 9.3% (27/289) had elevated blood sugar, and 11.4% (33/289) had elevated total cholesterol levels. This model could be replicated in other training settings to increase exposure to border health issues and connect patients to local health services.

Vulnerability in the clinic: case study of a transcultural consultation

Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.

Oregon's Emphasis On Equity Shows Signs Of Early Success For Black And American Indian Medicaid Enrollees

In 2012 Oregon transformed its Medicaid program, providing coverage through sixteen coordinated care organizations (CCOs). The state identified the elimination of health disparities as a priority for the CCOs, implementing a multipronged approach that included strategic planning, community health workers, and Regional Health Equity Coalitions. We used claims-based measures of utilization, access, and quality to assess baseline disparities and test for changes over time. Prior to the CCO intervention there were significant white-black and white-American Indian/Alaska Native disparities in utilization measures and white-black disparities in quality measures. The CCOs' transformation and implementation of health equity policies was associated with reductions in disparities in primary care visits and white-black differences in access to care, but no change in emergency department use, with higher visit rates persisting among black and American Indian/Alaska Native enrollees, compared to whites. States that encourage payers and systems to prioritize health equity could reduce racial and ethnic disparities for some measures in their Medicaid populations.

Searching for Silver Linings: Is Perceived Medical Discrimination Weaker in Segregated Areas?

An ongoing obstacle in dealing with minority health disparities is discriminatory behavior from healthcare practitioners, also known as medical discrimination. It is not clear, however, if the effects of medical discriminations onto health are constant across space. For example, there is evidence to suspect minorities in racially segregated neighborhoods suffer less from discrimination compared to those living elsewhere. To determine the presence of spatial heterogeneity underlying medical discrimination, we implement logistic geographically weighted regression (GWR) using individual data in the city of Philadelphia from the 2006 and 2008 Public Health Management Corporation's Southeastern Pennsylvania Household Health Surveys. Evaluating the potential role residential segregation has in offsetting medical discrimination, we compare the GWR results to tract data from the 2005-2009 American Community Survey. Through this comparison, we find that the effects of medical discrimination on self-rated health are weaker in magnitude in areas that are mostly minority. However, evidence of direct health benefits for minorities in segregated communities is inconclusive. Thus, while we cannot say living in segregated neighborhoods leads to better minority health, the sting of medical discrimination can be weaker in these places. These results emphasize the importance of local variation, even within a city like Philadelphia, challenging the aspatial one-model-fits-all approach normally found in population studies.

Response to culturally competent drug treatment among homeless persons with different living arrangements

This study investigated the association between program cultural competence and homeless individuals' drug use after treatment in Los Angeles County, California. Los Angeles County has the largest and most diverse population of homeless individuals in the nation. We randomly selected for analysis 52 drug-treatment programs and 2158 participants who identified as homeless in the Los Angeles County Participant Reporting System in 2011. We included their living arrangements (indoors and stable, indoors and unstable, and outdoors) and individual and program characteristics (particularly whether their programs used six culturally competent practices) in multilevel regression analyses. The outcome was days of primary drug use at discharge.Results showed that higher levels of staff personal involvement in minority communities (IRR=0.437; 95% CI=0.222, 0.861) and outreach to minority communities (IRR = 0.406; 95% CI=0.213, 0.771) were associated with fewer days of drug use at discharge. Homeless individuals living outdoors used their primary drug more often than any other group. Yet, compared to individuals with other living arrangements, when outdoor homeless individuals were treated by programs with the highest community resources and linkages (IRR=0.364; 95% CI=0.157, 0.844), they reported the fewest days of drug use. We discuss implications for program evaluation and community engagement policies and practices.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Factors affecting the cultural competence of visiting nurses for rural multicultural family support in South Korea

Background

With the recent growth of multicultural families in the Korean society, the importance of the role of qualified visiting nurses in the delivery of culturally sensitive health care has grown dramatically. As the primary health care provider for multicultural families enrolled in public community-based health care centers, the cultural competence of visiting nurses is an essential qualification for the provision of quality health care for multicultural families, especially in rural areas. Cultural competence of visiting nurses is based on their cultural awareness and empathetic attitude toward multicultural families. This study aimed to examine the levels of cultural competence, empowerment, and empathy in visiting nurses, and to verify the factors that affect the cultural competence of visiting nurses working with rural multicultural families in South Korea.

Methods

Employing a cross-sectional descriptive study design, data from 143 visiting nurses working in rural areas were obtained. Data collection took place between November 2011 and August 2012. The measurement tools included the modified Korean version of the Cultural Awareness Scale, the Text of Items Measuring Empowerment, and the Interpersonal Reactivity Index to measure the level of empathy of visiting nurses. Analyses included descriptive statistics, a t-test, an ANOVA, a Pearson correlation coefficient analysis, and a multiple linear regression analysis.

Results

The cultural competence score of the visiting nurses was 3.07 on a 5-point Likert scale (SD = 0.30). The multiple regression analysis revealed that the cultural competence of visiting nurses was significantly influenced by experience of cultural education, empathy, and scores on the meaning subscale of the empowerment tool (R² = 10.2%).

Conclusions

Institutional support to enhance visiting nurses' empowerment by assuring the significance of their job and specific strategies to enhance their empathy would be helpful to improve the cultural competence of visiting nurses. Additionally, regular systematic education on culturally sensitive care would be helpful to enable visiting nurses to provide culturally sensitive care for multicultural families.