Organizational characteristics that foster early adoption of cultural and linguistic competence in outpatient substance abuse treatment in the United States

Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs

INTRODUCTION

Substance use disorder (SUD) treatment programs offering addiction health services (AHS) must be prepared to adapt to change in their operating environment. These environmental uncertainties may have implications for service delivery, and ultimately patient outcomes. To adapt to a multitude of environmental uncertainties, treatment programs must be prepared to predict and respond to change. Yet, research on treatment programs preparedness for change is sparse. We examined reported difficulties in predicting and responding to changes in the AHS system, and factors associated with these outcomes.

METHODS

Cross-sectional surveys of SUD treatment programs in the United States in 2014 and 2017. We used linear and ordered logistic regression to examine associations between key independent variables (e.g., program, staff, and client characteristics) and four outcomes, (1) reported difficulties in predicting change, (2) predicting effect of change on organization, (3) responding to change, and (4) predicting changes to make to respond to environmental uncertainties. Data were collected through telephone surveys.

RESULTS

The proportion of SUD treatment programs reporting difficulty predicting and responding to changes in the AHS system decreased from 2014 to 2017. However, a considerable proportion still reported difficulty in 2017. We identified that different organizational characteristics are associated with their reported ability to predict or respond to environmental uncertainty. Findings show that predicting change is significantly associated with program characteristics only, while predicting effect of change on organizations is associated with program and staff characteristics. Deciding how to respond to change is associated with program, staff, and client characteristics, while predicting changes to make to respond is associated with staff characteristics only.

CONCLUSIONS

Although treatment programs reported decreased difficulty predicting and responding to changes, our findings identify program characteristics and attributes that could better position programs with the foresight to more effectively predict and respond to uncertainties. Given resource constraints at multiple levels in treatment programs, this knowledge might help identify and optimize aspects of programs to intervene upon to enhance their adaptability to change. These efforts may positively influences processes or care delivery, and ultimately translate into improvements in patient outcomes.

Determining the Organizational Cultural Competence of Hospitals Located in the Coastal Strip of the City of Antalya

AIM

This study aimed to determine the organizational cultural competence of hospitals located in the coastal strip of Antalya city in Turkey.

METHOD

The sample of this descriptive study included 31 hospitals. Data were collected with a questionnaire developed by the researchers under the guidance of 2 guides related to organizational cultural competency standards. The questionnaire included 3 sections and 47 questions and was answered by an authorized person to provide information on behalf of the hospital.

RESULTS

Among the hospitals participating in the study, 61.3% were private hospitals, 67.7% had international patient departments, 96.8% had quality departments, and 29% reported that they had a budget allocated for providing culturally appropriate care. Most of the hospitals reported that they served multi-menu option to the patients (64.5%) and provided with interpreter assistance free of cost (90.3%). Most of the hospitals stated that they provided end-of-life care for patients who died in their hospitals according to the wishes of the family members (96.8%).

CONCLUSION

Hospitals seek to adopt a culturally sensitive approach in healthcare services, but their cultural competence has scope for improvement, as they do not have strategic action plans or sufficient budgets yet.

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.

Nurse-Environment Interactions in the Development of Cultural Competence

Studies on the development of cultural competence among healthcare providers tend to focus on the clinical encounter, with little attention paid to the environment. In this paper, results from a grounded theory study conducted with nurses and students to understand cultural competence development are presented; with a focus on findings that call particular attention to nurse-environment interactions. Two concurrent processes, as students and nurses develop cultural competence through interactions with their environment, were identified: "dealing with structural constraints" and "mobilizing social resources". These dynamic interactions between healthcare providers and the larger structures of healthcare systems raise critical questions about the power of healthcare providers to influence the structures that shape their practice. The intersection of nursing theory with social and critical theories is essential to gain a comprehensive understanding of cultural competence development and to transform healthcare providers' education in the service of social justice and health equity.

Organizational implementation of evidence-based substance abuse treatment in racial and ethnic minority communities

We evaluated organizational factors associated with the implementation of contingency management treatment (CMT) and medication-assisted treatment (MAT) in substance abuse treatment (SAT) programs serving racial and ethnic minority communities. Analysis of cross-sectional data collected in 2010-2011 from a random sample of 148 publicly funded SAT programs showed that accepting private insurance was positively associated with CMT and MAT implementation, whereas larger programs were associated with greater implementation of MAT. Supervisorial openness to and expectations about implementing evidence-based practices (EBPs) and attributes for change were strongly associated with CMT, whereas the interactions between openness to EBPs and programs that accept private insurance and that are governed by parent organizations were positively associated with MAT. These external expectations and managerial attitudes supported the implementation of psychosocial and pharmacotherapy treatments in SAT. Implications for improving standards of care in minority communities are discussed.

The Final Frontier-Transitions and Sustainability: From Mentored to Independent Research

A recurrent theme in much of the contemporary HIV behavioral and social science research is that ecological approaches that acknowledge the interplay of structural, institutional, and individual-level factors are essential to improve HIV prevention efforts in racial/ethnic minority communities. Similarly, an ecological approach provides an innovative framework for understanding the challenges that many racial/ethnic minority HIV prevention researchers face in their quest to transition from mentored researcher to independent researchers. Informed by an ecological framework, and building on our experiences as two racial/ethnic minority women HIV prevention researchers who transitioned from a formal research mentorship relationship to become independent HIV prevention researchers-principal investigators of NIH-funded R01 grants-, we frame our discussion of the mentored to independence research trajectory with a focus on structural, institutional, and individual determinants. Throughout, we integrate suggestions for how institutions, mentors, and HIV prevention researchers can facilitate the final frontier from mentored research to independence.

Improving Coordination of Addiction Health Services Organizations with Mental Health and Public Health Services

In this mixed-method study, we examined coordination of mental health and public health services in addiction health services (AHS) in low-income racial and ethnic minority communities in 2011 and 2013. Data from surveys and semistructured interviews were used to evaluate the extent to which environmental and organizational characteristics influenced the likelihood of high coordination with mental health and public health providers among outpatient AHS programs. Coordination was defined and measured as the frequency of interorganizational contact among AHS programs and mental health and public health providers. The analytic sample consisted of 112 programs at time 1 (T1) and 122 programs at time 2 (T2), with 61 programs included in both periods of data collection. Forty-three percent of AHS programs reported high frequency of coordination with mental health providers at T1 compared to 66% at T2. Thirty-one percent of programs reported high frequency of coordination with public health services at T1 compared with 54% at T2. Programs with culturally responsive resources and community linkages were more likely to report high coordination with both services. Qualitative analysis highlighted the role of leadership in leveraging funding and developing creative solutions to deliver coordinated care. Overall, our findings suggest that AHS program funding, leadership, and cultural competence may be important drivers of program capacity to improve coordination with health service providers to serve minorities in an era of health care reform.

A constructivist theoretical proposition of cultural competence development in nursing

Cultural competence development in healthcare professions is considered an essential condition to promote quality and equity in healthcare. Even if cultural competence has been recognized as continuous, evolutionary, dynamic, and developmental by most researchers, current models of cultural competence fail to present developmental levels of this competence. These models have also been criticized for their essentialist perspective of culture and their limited application to competency-based approach programs. To our knowledge, there have been no published studies, from a constructivist perspective, of the processes involved in the development of cultural competence among nurses and undergraduate student nurses. The purpose of this study was to develop a theoretical proposition of cultural competence development in nursing from a constructivist perspective. We used a grounded theory design to study cultural competence development among nurses and student nurses in a healthcare center located in a culturally diverse urban area. Data collection involved participant observation and semi-structured interviews with 24 participants (13 nurses and 11 students) working in three community health settings. The core category, 'learning to bring the different realities together to provide effective care in a culturally diverse context', was constructed using inductive qualitative data analysis. This core category encompasses three dimensions of cultural competence: 'building a relationship with the other', 'working outside the usual practice framework', and 'reinventing practice in action.' The resulting model describes the concurrent evolution of these three dimensions at three different levels of cultural competence development. This study reveals that clinical experience and interactions between students or nurses and their environment both contribute significantly to cultural competence development. The resulting theoretical proposition of cultural competence development could be used not only to guide initial and continuing nursing education, but also to help redefine quality of care in a culturally diverse context.

Interventions to improve cultural competency in healthcare: a systematic review of reviews

Background

Cultural competency is a recognized and popular approach to improving the provision of health care to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities. The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field to form a comprehensive understanding of the current evidence base that can guide future interventions and research in the area.

Methods

A systematic review of review articles published between January 2000 and June 2012 was conducted. Electronic databases (including Medline, Cinahl and PsycINFO), reference lists of articles, and key websites were searched. Reviews of cultural competency in health settings only were included. Each review was critically appraised by two authors using a study appraisal tool and were given a quality assessment rating of weak, moderate or strong.

Results

Nineteen published reviews were identified. Reviews consisted of between 5 and 38 studies, included a variety of health care settings/contexts and a range of study types. There were three main categories of study outcomes: patient-related outcomes, provider-related outcomes, and health service access and utilization outcomes. The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilization outcomes but weaker evidence for improvements in patient/client outcomes.

Conclusion

This review of reviews indicates that there is some evidence that interventions to improve cultural competency can improve patient/client health outcomes. However, a lack of methodological rigor is common amongst the studies included in reviews and many of the studies rely on self-report, which is subject to a range of biases, while objective evidence of intervention effectiveness was rare. Future research should measure both healthcare provider and patient/client health outcomes, consider organizational factors, and utilize more rigorous study designs.

Organizational capacity for service integration in community-based addiction health services

OBJECTIVES

We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs.

METHODS

We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14 379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program.

RESULTS

Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing.

CONCLUSIONS

These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care.

Disparities in Latino substance use, service use, and treatment: implications for culturally and evidence-based interventions under health care reform

BACKGROUND

The goal of this systematic literature review was to enhance understanding of substance use, service use, and treatment among Latino subgroups to improve access to care and treatment outcomes in an era of health care reform.

METHODS

The authors used 13 electronic databases and manually searched the literature from January 1, 1978, to May 30, 2013. One hundred (69%) of 145 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus discussions and a content expert reconciled discrepancies.

RESULTS

Current rates of alcohol and substance abuse among Latinos are comparable to or surpass other U.S. ethnic groups. Disparities in access and quality of care are evident between Latinos and other ethnic groups. As a heterogeneous group, Latinos vary by geographic region in terms of substance of choice and their cultural identity takes precedence over general ethnic identity as a likely determinant of substance abuse behaviors. There is growing research interest in systems influencing treatment access and adherence among racial/ethnic and gender minority groups. However, studies on Latinos' service use and immediate treatment outcomes have been both limited in number and inconsistent in findings.

CONCLUSIONS

This review identified human capital, quality of care, and access to culturally responsive care as key strategies to eliminate disparities in health and treatment quality. Implications are discussed, including the need for effectiveness studies on Latinos served by systems of care that, under health care reform, are seeking to maximize resources, improve outcomes, and reduce variation in quality of care.

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.

Organizational structure, leadership and readiness for change and the implementation of organizational cultural competence in addiction health services

Increasing representation of racial and ethnic minorities in the health care system and on-going concerns about existing health disparities have pressured addiction health services programs to enhance their cultural competence. This study examines the extent to which organizational factors, such as structure, leadership and readiness for change contribute to the implementation of community, policy and staffing domains representing organizational cultural competence. Analysis of a randomly selected sample of 122 organizations located in primarily Latino and African American communities showed that programs with public funding and Medicaid reimbursement were positively associated with implementing policies and procedures, while leadership was associated with staff having greater knowledge of minority communities and developing a diverse workforce. Moreover, program climate was positively associated with staff knowledge of communities and having supportive policies and procedures, while programs with graduate staff and parent organizations were negatively associated with knowledge of and involvement in these communities. By investing in funding, leadership skills and a strategic climate, addiction health services programs may develop greater understanding and responsiveness of the service needs of minority communities. Implications for future research and program planning in an era of health care reform in the United States are discussed.

How the states stack up: disparities in substance abuse outpatient treatment completion rates for minorities

BACKGROUND

This study was an exploratory investigation of state-level minority disparities in successfully completing outpatient treatment, a major objective for attending substance abuse treatment and a known process outcome measure.

METHOD

This was a retrospective analysis of state discharge and admission data from the 2006 to 2008 Treatment Episode Datasets-Discharge (TEDS-D). Data were included representing all discharges from outpatient substance abuse treatment centers across the United States. All first treatment episode clients with admission/discharge records meeting inclusion criteria who could be classified as White, Latino, or Black/African American were used (n=940,058).

RESULTS

States demonstrated racial and ethnic disparities in their crude and adjusted completion rates, which also varied considerably among the states. Minorities typically showed a disadvantage. A few states showed significantly higher completion rates for Blacks or Latinos.

CONCLUSIONS

Realistically, a variety of factors likely cause the state race/ethnic differences in successful completion rates. States should investigate their delivery systems to reduce completion disparities.

Enhancing access and retention in substance abuse treatment: the role of Medicaid payment acceptance and cultural competence

BACKGROUND

Health insurance coverage and quality of care are common factors believed to improve access for and retention of racial and ethnic minority groups in health care. However, there is little evidence that acceptance of public insurance and provision of culturally responsive care decrease wait time and retention of minority populations in community-based substance abuse treatment.

METHODS

We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, CA. An analytical sample of 13,328 primarily African American and Latino clients nested within 104 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on count measures of days to initiate and days spent in treatment.

RESULTS

Programs that accepted public insurance (p<.001) and in which staff reported personal involvement (p<.01) and linkages and resources with minority communities (p<.001) were negatively associated with client wait time. Similarly, programs with culturally responsive policies and assessment and treatment practices (p<.05) were positively associated with retention in treatment, after controlling for individual and program characteristics.

CONCLUSIONS

These preliminary findings provide an evidentiary base for the role of community-based financial and cultural practices in improving accessibility and treatment adherence in a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to expand public insurance and enhance culturally competent care, are discussed.

Disparities in completion of substance abuse treatment among Latino subgroups in Los Angeles County, CA

RATIONALE

A growing body of research has revealed disparities with respect to drug use patterns within Latino subgroups. However, the extent to which these potential disparities enable different Latino subgroups to respond favorably to treatment is unclear.

METHODS

This study analyzed a subset of multicross-sectional data (2006-2009) on Latinos collected from publicly funded facilities in Los Angeles County, CA (N=12,871). We used multilevel logistic regressions to examine individual and service-level factors associated with treatment completion among subgroups of first-time Latino treatment clients.

RESULTS

Univariate analysis showed that Cubans and Puerto Ricans were less likely to complete treatment than Mexicans and other Latinos. Cubans and Puerto Ricans entered treatment at an older age and with higher formal education than Mexicans, yet they were more likely to report mental health issues and use of cocaine and heroin as primary drugs of choice respectively. Multivariate analysis showed that age, having mental health issues, reporting high use of drugs at intake, and use of methamphetamines and marijuana were associated with decreased odds of completing treatment among all Latino subgroups. In contrast, age at first drug use, treatment duration, and referral monitoring by the criminal system increased the odds of completing treatment for all members.

CONCLUSION

These findings have implications for targeting interventions for members of different Latinos groups during their first treatment episode. Promising individual and service factors associated with treatment completion can inform the design of culturally specific recovery models that can be evaluated in small-scale randomized pilot studies.

Do cultural and linguistic competence matter in Latinos' completion of mandated substance abuse treatment?

BACKGROUND

Increasing evidence suggests that culturally and linguistically responsive programs may improve substance abuse treatment outcomes among Latinos. However, little is known about whether individual practices or culturally and linguistically responsive contexts support efforts by first-time Latino clients to successfully complete mandated treatment.

METHODS

We analyzed client and program data from publicly funded treatment programs contracted through the criminal justice system in California. A sample of 5,150 first-time Latino clients nested within 48 treatment programs was analyzed using multilevel logistic regressions.

RESULTS

Outpatient treatment, homelessness, and a high frequency of drug use at intake were associated with decreased odds of treatment completion among Latinos. Programs that routinely offered a culturally and linguistically responsive practice-namely, Spanish-language translation-were associated with increased odds of completion of mandated treatment.

CONCLUSIONS

These preliminary findings suggest that concrete practices such as offering Spanish translation improve treatment adherence within a population that is at high risk of treatment dropout.

Workforce diversity in outpatient substance abuse treatment: the role of leaders' characteristics

Although the outpatient substance abuse treatment field has seen an increase in referrals of African American and Latino clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients. Program leaders have significant influence to leverage resources to develop staff diversity. Analysis of panel data from 1995 to 2005 showed that the most significant predictors of diversity were the characteristics of leaders. In particular, programs with managers with racially and ethnically concordant backgrounds and their education level were positively related to the percentage of Latino and African American staff. A high percentage of African American staff was positively associated with managers' tenure, but inversely related to licensed directors. Diversification of the field has increased, yet efforts have not matched increases in client diversity. Implications for health care reform legislation seeking to improve cultural competence through diversification of the workforce are discussed.