Moving towards culturally competent health systems: organizational and market factors

Shadow Coaching Improves Patient Experience for English-Preferring Patients but not for Spanish-Preferring Patients

BACKGROUND

Shadow coaching, a type of one-on-one provider counseling by trained peers, is an effective strategy for improving provider behaviors and patient interactions, but its effects on improving patient experience for English- and Spanish-preferring patients is unknown.

OBJECTIVE

Assess effects of shadow coaching on patient experience for English- and for Spanish-preferring patients.

DESIGN

We analyzed 2012-2019 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) data (n=46,089) from an urban Federally Qualified Health Center with 44 primary care practices and 320 providers. One-third (n=14,631) were Spanish-preferring patients. We fit mixed-effects regression models with random effects for provider (the level of treatment assignment) and fixed effects for time (a linear spline for time with a knot and "jump" at coaching date), patient characteristics, and site indicators, stratified by preferred language.

PARTICIPANTS

The 74 providers who had a 6-month average top-box score on the CAHPS overall provider rating below 90 (on a 100-point scale) were shadow coached. Similar percentages of English-preferring (45%) and Spanish-preferring patients (43%) were seen by coached providers.

INTERVENTION

Trained providers observed patient care by colleagues and provided suggestions for improvement. Verbal feedback was provided immediately after the observation and the participant received a written report summarizing the comments and recommendations from the coaching session.

MAIN MEASURES

CG-CAHPS Visit Survey 2.0 provider communication composite and overall provider rating (0-100 scoring).

KEY RESULTS

We found a statistically significant 2-point (small) jump in CAHPS provider communication and overall provider rating among English-preferring patients of coached providers. There was no evidence of a coaching effect on patient experience for Spanish-preferring patients.

CONCLUSIONS

Coaching improved care experiences for English-preferring patients but may not have improved patient experience for Spanish-preferring patients. Selection and training of providers to communicate effectively with Spanish-preferring patients is needed to extend the benefits of shadow coaching to Spanish-preferring patients.

A Cluster-Randomised Stepped-Wedge Impact Evaluation of a Pragmatic Implementation Process for Improving the Cultural Responsiveness of Non-Aboriginal Alcohol and Other Drug Treatment Services: A Pilot Study

There is limited evidence regarding implementing organisational improvements in the cultural responsiveness of non-Aboriginal services. Using a pragmatic implementation process to promote organisational change around cultural responsiveness, we aimed to (i) identify its impact on the cultural responsiveness of participating services; (ii) identify areas with the most improvement; and (iii) present a program logic to guide cultural responsiveness. A best-evidence guideline for culturally responsive service delivery in non-Aboriginal Alcohol and other Drug (AoD) treatment services was co-designed. Services were grouped geographically and randomised to start dates using a stepped wedge design, then baseline audits were completed (operationalization of the guideline). After receiving feedback, the services attended guideline implementation workshops and selected three key action areas; they then completed follow-up audits. A two-sample Wilcoxon rank-sum (Mann-Whitney) test was used to analyse differences between baseline and follow-up audits on three key action areas and all other action areas. Improvements occurred across guideline themes, with significant increases between median baseline and follow-up audit scores on three key action areas (median increase = 2.0; Interquartile Range (IQR) = 1.0-3.0) and all other action areas (median increase = 7.5; IQR = 5.0-11.0). All services completing the implementation process had increased audit scores, reflecting improved cultural responsiveness. The implementation process appeared to be feasible for improving culturally responsive practice in AoD services and may be applicable elsewhere.

Implementation gaps in culturally responsive care for refugee and migrant maternal health in New South Wales, Australia

BACKGROUND

Refugee and migrant women are at higher risk of childbirth complications and generally poorer pregnancy outcomes. They also report lower satisfaction with pregnancy care because of language barriers, perceived negative attitudes among service providers, and a lack of understanding of refugee and migrant women's needs. This study juxtaposes health policy expectations in New South Wales (NSW), Australia on pregnancy and maternity care and cultural responsiveness and the experiences of maternal healthcare providers in their day-to-day work with refugee and migrant women from non-English speaking backgrounds.

METHODS

This study used a qualitative framework method to allow for a comparison of providers' experiences with the policy expectations. Sixteen maternal health service providers who work with refugee and migrant women were recruited from two local health districts in New South Wales, Australia and interviewed (November 2019 to August 2020) about their experiences and the challenges they faced. In addition, a systematic search was conducted for policy documents related to the provision of maternal health care to refugee and migrant women on a state and federal level and five policies were included in the analysis.

RESULTS

Framework analysis revealed structural barriers to culturally responsive service provision and the differential impacts of implementation gaps that impede appropriate care resulting in moral distress. Rather than being the programmatic outcome of well-resourced policies, the enactment of cultural responsiveness in the settings studied relied primarily on the intuitions and personal responses of individual service providers such as nurses and social workers.

CONCLUSION

Authentic culturally responsive care requires healthcare organisations to do more than provide staff training. To better promote service user and staff satisfaction and wellbeing, organisations need to embed structures to respond to the needs of refugee and migrant communities in the maternal health sector and beyond.

Patient perspectives of the climate of diversity, equity, and inclusion in the emergency department

Objective

Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high-quality care to their diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED.

Methods

This was a cross-sectional survey study conducted in a large-volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus.

Results

During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement.

Conclusions

This DEI climate assessment survey of ED patients' perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.

Diversity-sensitive measures in German hospitals - attitudes, implementation, and barriers according to administration managers

Background

Populations have varying needs and expectations concerning health care that result from diversity characteristics such as a migrant background, gender identity, disability, and age. These needs and expectations must be considered to ensure adequate utilization and quality of health services. Approaches to address diversity do exist, however, little is known about the extent to which they are implemented by health care facilities. The present study aims to examine, which measures and structures hospitals in Germany employ to address diversity, as well as which barriers they encounter in doing so.

Methods

A mixed-mode survey among administration managers of all registered German hospitals (excluding rehabilitation hospitals; n = 1125) was conducted between May and October 2019 using pen-and-paper and online questionnaires. Results were analyzed descriptively.

Results

Data from n = 112 hospitals were available. While 57.1% of hospitals addressed diversity in their mission statement and 59.9% included diversity considerations in quality management, dedicated working groups and diversity commissioners were less prevalent (15.2% each). The majority of hospitals offered multi-lingual admission and exit interviews (59.8%), treatments or therapies (57.1%), but only few had multi-lingual meal plans (12.5%) and seminars or presentations (11.6%). While 41.1% of the hospitals offered treatment and/or nursing exclusively by staff of the same sex, only 17.0% offered group therapies for both sexes separately. According to the managers, the main barriers were a lack of financial resources (54.5%), a lack of incentives from the funding providers (49.1%), and organizational difficulties (45.5%). Other reported barriers were a lack of conviction of the necessity among decision makers (28.6%) and a lack of motivation among staff members (19.6%).

Conclusions

Administration managers from only a small proportion of hospitals participated in our survey on diversity sensitivity. Even hospitals of those who did are currently not adequately addressing the diversity of staff members and patients. Most hospitals address diversity on an ideational level, practical measures are not widely implemented. Existing measures suggest that most hospitals have no overarching concept to address diversity in a broader sense. The main reported barriers relate to economic aspects, a lack of support in organizing and implementing corresponding measures and a lack of awareness or motivation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08058-3.

Communication in Health Care: Impact of Language and Accent on Health Care Safety, Quality, and Patient Experience

Permanent or temporary migration results in communication issues related to language barriers. The migrant's mother tongue is often different from that of the host country. Even when the same language is spoken, communication barriers arise because of differences in accent. These communication barriers have a significant negative impact on migrants accessing health care and their ability to understand instructions and seek follow-up care. A multidisciplinary team often has professionals from various countries. These migrant health care professionals find it difficult to communicate with patients of the host country and with their colleagues. Communication barriers, therefore, result in miscommunication or no communication between health care professionals and between health care professionals and patients. This increases the risk of medical errors and impacts quality of care and patient safety. This review looks at the impact of communication barriers in health care and endeavors to find effective solutions.

The Relationship Between "Leader in LGBT Healthcare Equality" Designation and Hospitals' Patient Experience Scores

EXECUTIVE SUMMARY

An increasing number of lesbian, gay, bisexual, and transgender (LGBT) individuals openly acknowledge their identity; however, the fear of discrimination prevents many from seeking healthcare-an issue challenged by a lack of culturally competent LGBT healthcare providers. With more than 4% of American adults identifying as LGBT individuals, greater attention to their needs is imperative to improve care and access for this population. This study examined organizational and market factors associated with hospitals achieving the "Leader in LGBT Healthcare Equality" (Healthcare Equality Index, HEI; HEI Leader) designation and reported patient experience scores. We found that system-affiliated hospitals have 4.16 greater odds and teaching hospitals have 2.86 greater odds of earning the HEI Leader designation compared to nonsystem and nonteaching hospitals, respectively. Governmental hospitals have 2.47 greater odds of achieving HEI Leader status, while for-profit hospitals have 86% lower odds of having HEI Leader status compared to not-for-profit hospitals. Hospitals located in a metropolitan area have 3.19 greater odds of being an HEI Leader. The percentage of minorities and per capita income in a county also demonstrated a positive association with being an HEI Leader, with odds ratios of 1.00 and 1.02, respectively, while lower education was associated with 4% lower odds of being an HEI Leader. The main finding of this study was that HEI Leader-designated hospitals reported significantly higher overall hospital rating patient experience scores (B = 1.785; p ≤ .001) as compared to non-HEI Leader hospitals. As such, participation in the HEI may be viewed as a motivation for hospitals attaining HEI Leader designation.

Cultural intelligence and social distance among undergraduate students in clinical professions

Cultural competence, also known as cultural intelligence (CQ), is considered a necessary skill in the clinical professions and for resolving intergroup conflict, yet it has not been examined within the framework of the contact hypothesis. The aim of the present research is to extend CQ theory from management to the clinical professions and examine it in a context of intergroup conflict. The present study examined CQ and social distance among entering undergraduate majority (Jewish) and minority (Arab) students in clinical study domains, hypothesizing that CQ will be negatively associated with social distance towards outgroup members and that minority students will report higher CQ than majority students. First-year students ( N = 180) from diverse demographic and study domains (social work, nursing, behavioral sciences) were surveyed. The results reveal a novel negative association between CQ and outgroup social distance, and higher CQ among minority-group students. The finding that students from minority backgrounds were more receptive to intercultural exchange at the outset of their training suggests that CQ theory could be used in training and evaluation criteria of students entering clinical professional training.

Culturally and Linguistically Appropriate Hospital Services Reduce Medicare Length of Stay

Introduction

Almost 40% of the 63 million Americans who speak a language other than English have limited English proficiency (LEP). This communication barrier can result in poor quality care and potentially adverse health outcomes. Of particular interest is that the greatest proportion of LEP adults are aged >65 years and will face barriers and delays in accessing high-quality care. Age cohort variation of LEP burden has not been widely addressed. Culturally and linguistically appropriate hospital care delivery can mitigate these barriers.

Methods

In order to test whether culturally competent services reduced length-of-stay (LOS), we linked organizational cultural competence surveys across two-states (CA+FL) for comparison across Medicare acute care LOS. Using the 2013 American Hospital Association Database, and Hospital Compare Data from CMS (N=184), we compared hospital structure with culturally and linguistically appropriate services related to improved care delivery for LEP populations and aging LEP populations. We utilized Kruskal-Wallis to test group differences and a negative binomial regression to model median LOS. All analyses were conducted using SAS 9.4 (Cary, NC).

Results

Median LOS across all hospitals was 4.7 days (mean 5.7, standard deviation 6.3). Most hospitals were not-for-profit (46.7%), small (<150 beds, 54.4%), Joint Commission accredited (67.9%), and in urban areas. We found shorter median LOS when hospital units identified cultural or language needs at admission (Wald χ23.82, P=.0506). Hospitals' identification of these needs at discharge had no impact on LOS. Hospitals that accommodated patient cultural or ethnic dietary needs also reported lower median LOS (Wald χ2 12.93, P=.0003). Structurally, public hospitals, accredited hospitals, and hospitals that reported system membership were predictive of a lower median LOS.

Discussion

Our findings demonstrate that patient outcomes are responsive to culturally and linguistically appropriate services. Further, our findings suggest understanding of culturally competent care in hospitals is lacking. A larger and multi-level sample across the United States could yield a greater understanding of the role of culturally and linguistically appropriate care for a rapidly growing population of diverse older adults.

Diversity Management as a Tool for Sustainable Development of Health Care Facilities

Organizations providing health services are often criticized because of inadequate and unsuitable management processes or procedures. Today’s challenge is focused on effective management and leadership skills in the area of health care. The aim of the research is to describe, analyze, and evaluate the current state of diversity management in details in the context of human resources management in the selected healthcare facilities. The source of the information was a questionnaire survey. The sample consists of 181 managers from various health care and health service organizations. The method of analysis of variance (ANOVA) was used for data processing. The results were processed in SPSS and Excel programs. Pearson’s coefficient was used to evaluate the cross-correlation of the variables. The level of significance was 5% on both sides. Basic awareness of diversity management in the healthcare facilities is low. Some tools of diversity management are used, but only in isolation, non-conceptually, and unsystematically. The acknowledgment of diversity concept is poor and chaotic. The basic models of this concept defining its goals, activities, programs, responsibilities, and measurements are not known. One of the strong areas of the diversity management in the healthcare facilities is the diversity of working teams. On other hand, the weak side is the diversity as part of the organization culture and diversity as a part of human resource management. The summarizing index Attitudes towards Diversity received a higher average value than the Diversity Management Implementation index. Significant variables influencing the level of aggregate indices were identified: Ownership, size of the organization in terms of number of employees, patients’ satisfaction, and employees’ satisfaction.

Diverse and Complex Challenges to Migrant and Refugee Mental Health: Reflections of the M8 Alliance Expert Group on Migrant Health

Forced migration is likely to continue to grow in the coming years due to climate change, disease outbreaks, conflict, and other factors. There are a huge number of challenges to maintaining good health, and specifically good mental health, among migrants at all stages of migration. It is vital to fully understand these diverse challenges so that we can work towards overcoming them. In 2017, as a response to the growing health challenges faced by migrants and refugees, the M8 Alliance created an expert group focussing on migrant and refugee health. The group meets annually at the Sapienza University of Rome, Italy, and this article is based on the discussions that took place at the third annual meeting (6–7 June 2019) and a special session on “Protecting the Mental Health of Refugees and Migrants,” which took place on 27 October at the World Health Summit 2019 in Berlin. Our discussions are also supported by supplementary literature to present the diverse and complex challenges to the mental health of migrants and refugees. We conclude with some lessons learned and hope for the future.

Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study

Ethnic minorities across the globe encounter disparities in healthcare. While a great deal of research has been conducted on the experiences of these patients, studies focusing on the perspectives of healthcare professionals are limited, particularly in the context of Asia. This study explores the perceptions of and challenges faced by Hong Kong healthcare professionals in the provision of culturally appropriate care to South Asian ethnic minority patients. Taking a qualitative approach, interviews were conducted with 22 healthcare professionals. Two main themes were identified: 'lack of support' at the healthcare system level and 'dysfunctional relationship with South Asian ethnic minority patients' at the interpersonal level. Challenges at the healthcare system level include information outreach, cultural competency, utilisation of available resources and time and workload, whereas challenges at the interpersonal level include patient-provider interaction, patient-provider perceptions of illness and care and patient-provider sociocultural discordance. Intercultural care was found to be influenced by both the healthcare system and interpersonal characteristics. The study highlights the need for healthcare professional education and training in cultural competency, in order to improve the provision of intercultural care. Identifying the challenges faced by healthcare professionals and the implications of these challenges for the provision of healthcare to South Asian ethnic minority patients will help practitioners, policy makers and care provider agencies to improve quality of care and health outcomes for culturally diverse patients.

Improving Medical Tourism Services through Human Behaviour and Cultural Competence

BACKGROUND

Medical tourism is a type of service sector in which there is direct interaction between healthcare practitioners and patient-customers, leading to several challenges due to cultural and social background differences. We aimed to investigate the determinants of delivering a culturally-oriented service in medical tourism sector.

METHODS

Adopting an exploratory qualitative approach, interviews were conducted through a semi-structured procedure with authorities across various medical sectors in South Korea in winter 2017. Participants were all involved in and aware of the medical tourism sector, both academically and clinically. The interview transcripts were coded through a systematic thematic analysis.

RESULTS

In order to focus on non-clinical service in medical tourism sector, and a system of cultural competence delivery, three main themes were identified: 1) The personal characteristics of doctors; 2) External supports to be provided by the associated organisations; and finally, 3) Skilfulness, which implies the culturally-oriented interaction with foreign patients.

CONCLUSION

Several strategies are suggested to address the non-clinical challenges and conflicts in doctor-patient interaction in the sector of medical tourism. It is likely that providing a culturally-oriented service in this sector demands for a comprehensive planning, and several strategies for implementation in order to support and train a team of skilful doctors with non-clinical characteristics. These finding will likely have insights for those organisations searching to improve their performance in the medical tourism sector.

What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting

Background

Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting.

Methods

In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison.

Results

Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them.

Conclusions

In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don’t fall through the gaps with regards to the provision of culturally competent care.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7378-9) contains supplementary material, which is available to authorized users.

Cultural Competence and Ethnic Diversity in Healthcare

Today's model of healthcare has persistent challenges with cultural competency, and racial, gender, and ethnic disparities. Health is determined by many factors outside the traditional healthcare setting. These social determinants of health (SDH) include, but are not limited to, education, housing quality, and access to healthy foods. It has been proposed that racial and ethnic minorities have unfavorable SDH that contributes to their lack of access to healthcare. Additionally, African American, Hispanic, and Asian women have been shown to be less likely to proceed with breast reconstructive surgery post-mastectomy compared to Caucasian women. At the healthcare level, there is underrepresentation of cultural, gender, and ethnic diversity during training and in leadership. To serve the needs of a diverse population, it is imperative that the healthcare system take measures to improve cultural competence, as well as racial and ethnic diversity. Cultural competence is the ability to collaborate effectively with individuals from different cultures; and such competence improves health care experiences and outcomes. Measures to improve cultural competence and ethnic diversity will help alleviate healthcare disparities and improve health care outcomes in these patient populations. Efforts must begin early in the pipeline to attract qualified minorities and women to the field. The authors are not advocating for diversity for its own sake at the cost of merit or qualification, but rather, these efforts must evolve not only to attract, but also to retain and promote highly motivated and skilled women and minorities. At the trainee level, measures to educate residents and students through national conferences and their own institutions will help promote culturally appropriate health education to improve cultural competency. Various opportunities exist to improve cultural competency and healthcare diversity at the medical student, resident, attending, management, and leadership levels. In this article, the authors explore and discuss various measures to improve cultural competency as well as ethnic, racial, and gender diversity in healthcare.

Inpatient care experiences differ by preferred language within racial/ethnic groups

Objective

To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups.

Data Source

2014‐2015 HCAHPS survey data.

Study Design

We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient‐mix adjusted overall, between‐ and within‐hospital differences in patient experience by language, using linear regression.

Data Collection Methods

Surveys from 5 480 308 patients discharged from 4517 hospitals 2014‐2015.

Principal Findings

Within each racial/ethnic group, mean reported experiences for non‐English‐preferring patients were almost always worse than their English‐preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within‐hospital differences by language were often larger than between‐hospital differences and were largest for Care Coordination. Where between‐hospital differences existed, non‐English‐preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English‐preferring counterparts.

Conclusions

Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non‐English‐preferring patients, focusing on cultural competence and language‐appropriate services.

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries' approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country's culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples' self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.

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.

Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature

INTRODUCTION

Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research.

METHODS

A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported.

RESULTS

Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level.

DISCUSSION AND IMPLICATIONS

We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities.

An ethnographic investigation of the maternity healthcare experience of immigrants in rural and urban Alberta, Canada

Background

Canada is among the top immigrant-receiving nations in the world. Immigrant populations may face structural and individual barriers in the access to and navigation of healthcare services in a new country. The aims of the study were to (1) generate new understanding of the processes that perpetuate immigrant disadvantages in maternity healthcare, and (2) devise potential interventions that might improve maternity experiences and outcomes for immigrant women in Canada.

Methods

The study utilized a qualitative research approach that focused on ethnographic research design and data analysis contextualized within theories of organizational behaviour and critical realism. Data were collected over 2.5 years using focus groups and in-depth semistructured interviews with immigrant women (n = 34), healthcare providers (n = 29), and social service providers (n = 23) in a Canadian province. Purposive samples of each subgroup were generated, and recruitment and data collection – including interpretation and verification of translations – were facilitated through the hiring of community researchers and collaborations with key informants.

Results

The findings indicate that (a) communication difficulties, (b) lack of information, (c) lack of social support (isolation), (d) cultural beliefs, e) inadequate healthcare services, and (f) cost of medicine/services represent potential barriers to the access to and navigation of maternity services by immigrant women in Canada. Having successfully accessed and navigated services, immigrant women often face additional challenges that influence their level of satisfaction and quality of care, such as lack of understanding of the informed consent process, lack of regard by professionals for confidential patient information, short consultation times, short hospital stays, perceived discrimination/stereotyping, and culture shock.

Conclusions

Although health service organizations and policies strive for universality and equality in service provision, personal and organizational barriers can limit care access, adequacy, and acceptability for immigrant women. A holistic healthcare approach must include health informational packages available in different languages/media. Health care professionals who care for diverse populations must be provided with training in cultural competence, and monitoring and evaluation programs to ameliorate personal and systemic discrimination.

Advancing Organizational Cultural Competency With Dissemination and Implementation Frameworks: Towards Translating Standards into Clinical Practice

Substantial public health efforts have been activated to reduce health disparities and ensure health equity for patients through the provision of culturally and linguistically appropriate services; yet associated policies and standards are sluggishly translating into practice. Little attention and resources have been dedicated to translation of public health policies into practice settings. Dissemination and implementation is presented as an active, strategic approach to enhance uptake of public health standards; reviews dissemination and implementation concepts; poses a systematic model to adoption, implementation, and dissemination; and concludes with recommendations for hospital-based implementation teams and complementary interprofessional collaboration.

Perceptions of health system orientation: quality, patient centeredness, and cultural competency

As part of a pragmatic trial to reduce hypertension disparities, we conducted a baseline organizational assessment to identify aspects of organizational functioning that could affect the success of our interventions. Through qualitative interviewing and the administration of two surveys, we gathered data about health care personnel's perceptions of their organization's orientations toward quality, patient centeredness, and cultural competency. We found that personnel perceived strong orientations toward quality and patient centeredness. The prevalence of these attitudes was significantly higher for these areas than for cultural competency and varied by occupational role and race. Larger percentages of survey respondents perceived barriers to addressing disparities than barriers to improving safety and quality. Health care managers and policy makers should consider how we have built strong quality orientations and apply those lessons to cultural competency.

Predictors of language service availability in U.S. hospitals

BACKGROUND

Hispanics comprise 17% of the total U.S. population, surpassing African-Americans as the largest minority group. Linguistically, almost 60 million people speak a language other than English. This language diversity can create barriers and additional burden and risk when seeking health services. Patients with Limited English Proficiency (LEP) for example, have been shown to experience a disproportionate risk of poor health outcomes, making the provision of Language Services (LS) in healthcare facilities critical. Research on the determinants of LS adoption has focused more on overall cultural competence and internal managerial decision-making than on measuring LS adoption as a process outcome influenced by contextual or external factors. The current investigation examines the relationship between state policy, service area factors, and hospital characteristics on hospital LS adoption.

METHODS

We employ a cross-sectional analysis of survey data from a national sample of hospitals in the American Hospital Association (AHA) database for 2011 (N= 4876) to analyze hospital characteristics and outcomes, augmented with additional population data from the American Community Survey (ACS) to estimate language diversity in the hospital service area. Additional data from the National Health Law Program (NHeLP) facilitated the state level Medicaid reimbursement factor.

RESULTS

Only 64% of hospitals offered LS. Hospitals that adopted LS were more likely to be not-for-profit, in areas with higher than average language diversity, larger, and urban. Hospitals in above average language diverse counties had more than 2-fold greater odds of adopting LS than less language diverse areas [Adjusted Odds Ratio (AOR): 2.26, P< 0.01]. Further, hospitals with a strategic orientation toward diversity had nearly 2-fold greater odds of adopting LS (AOR: 1.90, P< 0.001).

CONCLUSION

Our findings support the importance of structural and contextual factors as they relate to healthcare delivery. Healthcare organizations must address the needs of the population they serve and align their efforts internally. Current financial incentives do not appear to influence adoption of LS, nor do Medicaid reimbursement funds, thus suggesting that further alignment of incentives. Organizational and system level factors have a place in disparities research and warrant further analysis; additional spatial methods could enhance our understanding of population factors critical to system-level health services research.