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

Cultural competence and safety in Circumpolar countries: an analysis of discourses in healthcare

Circumpolar Indigenous populations continue to experience dramatic health inequities when compared to their national counterparts. The objectives of this study are first, to explore the space given in the existing literature to the concepts of cultural safety and cultural competence, as it relates to Indigenous peoples in Circumpolar contexts; and second, to document where innovations have emerged. We conducted a review of the English, Danish, Norwegian, Russian and Swedish Circumpolar health literature focusing on Indigenous populations. We include research related to Alaska (USA); the Yukon, the Northwest Territories, Nunavik and Labrador (Canada); Greenland; Sápmi (northmost part of Sweden, Norway, and Finland); and arctic Russia. Our results show that the concepts of cultural safety and cultural competence (cultural humility in Nunavut) are widely discussed in the Canadian literature. In Alaska, the term relationship-centred care has emerged, and is defined broadly to encompass clinician-patient relationships and structural barriers to care. We found no evidence that similar concepts are used to inform service delivery in Greenland, Nordic countries and Russia. While we recognise that healthcare innovations are often localised, and that there is often a lapse before localised innovations find their way into the literature, we conclude that the general lack of attention to culturally safe care for Sámi and Greenlandic Inuit is somewhat surprising given Nordic countries' concern for the welfare of their citizens. We see this as an important gap, and out of step with commitments made under United Nations Declarations on the Rights of Indigenous Peoples. We call for the integration of cultural safety (and its variants) as a lens to inform the development of health programs aiming to improve Indigenous in Circumpolar countries.

Latino Health Access: Comparative Effectiveness of a Community-Initiated Promotor/a-Led Diabetes Self-management Education Program

Community-initiated health interventions fill important gaps in access to health services. This study examines the effectiveness of a community-initiated health intervention to improve diabetes management in an underserved community of color using a retrospective observational study, comparing a study intervention, the Latino Health Access Diabetes Self-Management Program (LHA-DSMP), with usual care. The LHA-DSMP is a 12-session community health worker (promotor/a) intervention developed and implemented by a community-based organization in a medically underserved area. Usual care was delivered at a federally qualified health center in the same geographic area. Participants were 688 predominantly Spanish-speaking Latinx adults with type 2 diabetes. The main outcome was change in glycemic control (glycosylated hemoglobin [HbA1c]) from baseline to follow-up. At 14-week follow-up, mean (95% CI) HbA1c decrease was -1.1 (-1.3 to -0.9; P < .001) in the LHA-DSMP cohort compared with -0.3 (-0.4 to -0.2; P < .001) in the comparison cohort. Controlling for baseline differences between cohorts, the adjusted difference-in-differences value in HbA1c was -0.6 (-0.8 to -0.3; P < .001) favoring the LHA-DSMP. A community-initiated promotor/a-led educational program for diabetes self-management is associated with clinically significant improvement in blood sugar control, superior to what was observed with usual medical care.

Minority Adolescent Mental Health Diagnosis Differences in a National Sample

INTRODUCTION

Mental health disparities and differences have been identified amongst all age groups, including adolescents. However, there is a lack of research regarding adolescents within the Military Health System (MHS). The MHS is a universal health care system for military personnel and their dependents. Research has indicated that the MHS removes many of the barriers that contribute to health disparities. Additional investigations with this population would greatly contribute to our understanding of disparities and health services delivery without the barrier of access to care.

MATERIALS AND METHODS

This study analyzed the diagnostic trends of anxiety, depression, and impulse control disorders and differences within a national sample of adolescents of active-duty military parents. The study utilized 2006 to 2014 data in the MHS Data Repository for adolescents ages 13-18. The study identified 183,409 adolescents with at least one diagnosis. Multivariable logistic regressions were conducted to assess the differences and risks for anxiety, depression, and impulse control disorders in the identified sample.

RESULTS

When compared to White Americans, minority patients had a higher likelihood of being diagnosed with an impulse control disorder (odds ratio [OR] = 1.43; confidence interval [CI] 1.39-1.48) and a decreased likelihood of being diagnosed with a depressive disorder (OR = 0.98; CI 0.95-1.00) or anxiety disorder (OR = 0.80; CI 0.78-0.83). Further analyses examining the subgroups of minorities revealed that, when compared to White Americans, African American adolescents have a much higher likelihood of receiving a diagnosis of an impulse control disorder (OR = 1.66; CI 1.61-1.72) and a lower likelihood of receiving a diagnosis of a depressive disorder (OR = 0.93; CI 0.90-0.96) and an anxiety disorder (OR = 0.75; CI 0.72-0.77).

CONCLUSION

This study provides strong support for the existence of race-based differences in adolescent mental health diagnoses. Adolescents of military families are a special population with unique experiences and stressors and would benefit from future research focusing on qualitative investigations into additional factors mental health clinicians consider when making diagnoses, as well as further exploration into understanding how best to address this special population's mental health needs.

An Opportunity to Integrate Cultural Sensitivity Training Into the Doctor of Pharmacy Curriculum

Instructors of pharmacy skills-based laboratory courses are positioned to prepare students to be practice-ready practitioners through use of hands-on instructional activities essential for pharmacists. This commentary explores an approach to developing cultural sensitivity in pharmacy students, a skill which is reflected in Accreditation Council for Pharmacy Education (ACPE) Standard 3.5 and viewed by the authors as a critical skill for all healthcare practitioners. This commentary challenges the Academy to develop best practices for promoting cultural sensitivity in student-learners with the goal of producing students aware of how their own experiences may influence health inequities. The authors propose, using the model of self-efficacy theory as a framework, that skills-based pharmacy education is an ideal platform for cultural sensitivity skill development and engagement because of its ability to go beyond knowledge attainment and influence student abilities, behaviors, and attitudes. The authors' recommendations include that members of the Academy self-assess personal and institutional cultural sensitivity, ensure integration of cultural sensitivity in curriculum, use self-efficacy theory as a guide to integrate best practices for providing culturally sensitive care in laboratory activities, and develop best practices.

Yindyamarra Winhanganha: a Conduit to Indigenous Cultural Proficiency

The first nation peoples in the USA, Canada, Australia and around the world are substantially disadvantaged by colonialization including health inequity. For nuclear medicine, cultural competence of staff and cultural proficiency of the institution, are important minimum expectations. This can be achieved through a scaffold of Indigenous cultural training and immersion programs that allow the nuclear medicine department to be a culturally safe environment for Indigenous patients. This requires careful planning and inclusivity of Indigenous people as the key stakeholders but, done appropriately, can positively drive the Indigenous equity pipeline. Central to this is an understanding of Indigenous ways of learning and the nexus of these ways of learning and learning taxonomies. There remain substantial gaps between the most culturally insightful and the least insightful (individuals and institutions) that could be addressed, in part, by rich immersive professional development activities in nuclear medicine targeting cultural proficiency and creating culturally safe clinical environments. The opportunity lies before us to provide leadership in nation building and in living respectfully while creating a world worth living in; yindyamarra winhanganha.

Telephone Patient Navigation Increases Follow-Up Hepatitis B Care in the Postpartum Period for Immigrants Living in New York City

Hepatitis B is a major public health threat which leads to serious liver disease or cancer and disproportionately impacts immigrants. Pregnant people are routinely tested for hepatitis B to prevent perinatal transmission but may themselves not receive appropriate education and referrals. People contacted as part of the local health department's perinatal hepatitis B prevention program were offered culturally appropriate telephone patient navigation services to test if this would improve adherence with postpartum hepatitis B care. Four-hundred and nine people were enrolled in the intervention. Using laboratory-reported surveillance data as the outcome measure, those receiving the intervention were 1.66 times as likely to see a hepatitis B care provider within 6 months of childbirth compared with those who did not. Culturally appropriate patient navigation can improve adherence with recommended hepatitis B care in the postpartum period. Health departments can use similar interventions to address liver health disparities in immigrant populations.

Welche Faktoren fördern und behindern die Umsetzung migrationssensibler Versorgung?

Hintergrund Menschen mit Migrationshintergrund nehmen trotz eines höheren Bedarfs rehabilitative Leistungen seltener in Anspruch und weisen ungünstigere Ergebnisse auf als Menschen ohne Migrationshintergrund. Migrationssensible Versorgungsstrategien können einen Beitrag leisten, Barrieren abzubauen, denen Menschen mit Migrationshintergrund im Gesundheitssystem begegnen. Ziel der vorliegenden Studie ist es, hindernde und fördernde Faktoren für die Implementierung solcher Strategien aus der Perspektive von Gesundheitspersonal zu ermitteln.

Methodik Die Untersuchung basiert auf 8 qualitativen leitfadengestützten Fokusgruppeninterviews mit insgesamt 50 MitarbeiterInnen unterschiedlicher Berufsgruppen in orthopädischen Rehabilitationseinrichtungen in Nordrhein-Westfalen und Schleswig-Holstein.

Ergebnisse Das Gesundheitspersonal erachtet eine migrationssensible Versorgung als notwendig und ist motiviert, entsprechende Maßnahmen umzusetzen. Als Hindernis für die Implementierung werden v. a. fehlende personelle und finanzielle Ressourcen genannt, u.a. für das Einstellen zusätzlicher mehrsprachiger MitarbeiterInnen. Optimierungspotenziale wurden im Hinblick auf die fehlende Migrationssensibilität von Versorgungsträgern gesehen.

Schlussfolgerung Die aufgezeigten Barrieren müssen überwunden werden, um den Einsatz migrationssensibler Versorgungskonzepte zu fördern. Diese können der Ausgangspunkt für eine über Migrationssensibilität hinausgehende diversitätssensible Versorgung sein, die auch der Rolle weiterer Diversitätsmerkmale Rechnung trägt.

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.

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.

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.

Drawing them in: professional perspectives on the complexities of engaging 'culturally diverse' young people with sexual and reproductive health promotion and care in Sydney, Australia

Young people from minority ethnic, migrant and refugee backgrounds are widely recognised as being under-served by mainstream sexual and reproductive healthcare in developed economy nations. This paper documents the views of professionals in Australia on the complexities of, and best practice approaches to, engaging members of this group with sexual and reproductive health promotion and care. Semi-structured interviews were conducted with 23 purposively selected key informants (health service providers, policymakers, academics and community advocates). Interviews were transcribed verbatim and coded in NVivo10 using interpretive thematic analysis. Principles of 'cultural competence' were employed to structure the interpretation of findings. Five key themes reveal pivotal aspects of how professionals work in, and make sense of, this complex field. These may be summarised as: (1) appreciating the complexities of cultural diversity; (2) recognising structural barriers and disincentives to engagement; (3) normalising sexual health; (4) balancing 'youth-friendly' and 'culturally-competent' priorities; and (5) going beyond simple translation. As migration to Australia continues to diversify the population, an integrated, national approach to the design and delivery of sexual and reproductive health promotion and care would be of value, along with training and support for those involved. Implications may have resonance for other countries similarly engaged in facilitating the successful settlement of migrants and refugees.

The Implementation and Evaluation of Health Promotion Services and Programs to Improve Cultural Competency: A Systematic Scoping Review

BACKGROUND

Cultural competency is a multifaceted intervention approach, which needs to be implemented at various levels of health-care systems to improve quality of care for culturally and ethnically diverse populations. One level of health care where cultural competency is required is in the provision of health promotion services and programs targeted to diverse patient groups who experience health-care and health inequalities. To inform the implementation and evaluation of health promotion programs and services to improve cultural competency, research must assess both intervention strategies and intervention outcomes.

METHODS

This scoping review was completed as part of a larger systematic literature search conducted on evaluations 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. Overall, 64 studies on cultural competency interventions were found, with 22 being health promotion programs and services. A process of thematic analysis was utilized to identify key intervention strategies and outcomes reported in the literature.

RESULTS

The review identified three overarching strategies utilized in health promotion services and programs to improve cultural competency: community-focused strategies, culturally focused strategies, and language-focused strategies. Studies took different approaches to delivering culturally competent health interventions, with the majority incorporating multiple strategies from each overarching category. There were various intermediate health-care and health outcomes reported across the included studies. Most commonly reported were positive reports of patient satisfaction, patient/participant service access, and program/study retention rates. The health outcome results indicate positive potential of health promotion services and programs to improve cultural competency to impact cardiovascular disease and mental health outcomes. However, due to measurement and study quality issues, it is difficult to determine the extent of the impacts.

DISCUSSION

Examined together, these intervention strategies and outcomes provide a framework that can be used by service providers and researchers in the implementation and evaluation of health promotion services and programs to improve cultural competency. While there is evidence indicating the effectiveness of such health promotion interventions in improving intermediate and health outcomes, further attention is needed to issues of measurement and study quality.

Identifying Gaps in the Cultural Competence/Sensitivity Components of an Undergraduate Medical School Curriculum: A Needs Assessment

Physicians and other health care workers are increasingly being called upon to bridge the cultural differences that may exist between themselves and their patients. Adequate cross-cultural education is essential if existing health care disparities are to be reduced. We conducted a needs assessment to identify gaps in the cultural competence/sensitivity components of the undergraduate medical school curriculum at Case Western Reserve University School of Medicine. The 2011 study was designed (1) to assess how first and second year medical school students perceive the adequacy of the medical school curriculum with respect to issues of diversity and (2) the extent to which first and second year medical students believe that an understanding of issues relating to patient culture are important to the provision of effective patient care. Student perspectives were assessed through a web-based anonymous survey of all first year (n = 167) and all second year (n = 166) medical school students, two focus groups (total n = 14) and a Problem-based Case Inquiry Group exercise (n = 6), both with second year students. A substantial proportion of participating first and second year medical students do not believe that self-reflection regarding one's own cultural biases is important to one's performance as a physician, do not view an understanding of diverse patient cultural beliefs as important or very important in the provision of effective patient care, and are uncomfortable with and unsure about how to approach culture-related issues arising in patient care. The inclusion of specified elements--increased contact with diverse patients, more comprehensive resources, increased opportunities to practice communication skills and engage in self-reflection--may be critical to heighten student awareness of and comfort in interacting with diverse populations. Our findings are relevant to the development of medical school curricula designed to improve physician understanding of and responsiveness to diverse patient populations and efforts to reduce health disparities.

Pharmacy students' use of and beliefs about traditional healthcare

Health professional students come from many different cultural backgrounds, and may be users of traditional healthcare (also known as ethnomedicine or folk medicine). This study aimed to explore New Zealand pharmacy students' knowledge and beliefs about traditional healthcare, and to examine whether these changed during the course. A questionnaire was administered to students in 2011 and again in 2013. Students were from a wide range of ethnic groups. Their reported use of traditional healthcare increased (from 48% in 2011 to 61% in 2013) and was usually for minor illness or prevention. Non New Zealand European students were more likely to use traditional healthcare. Use of traditional healthcare was relatively common, and after exposure to a biomedical curriculum students seemed to be more, rather than less likely to report using traditional healthcare. Education about traditional healthcare should not be based on the assumption that all healthcare students are unfamiliar with, or non-users of, traditional healthcare.

Cultural Humility and Hospital Safety Culture

Hospital safety culture is an integral part of providing high quality care for patients, as well as promoting a safe and healthy environment for healthcare workers. In this article, we explore the extent to which cultural humility, which involves openness to cultural diverse individuals and groups, is related to hospital safety culture. A sample of 2011 hospital employees from four hospitals completed measures of organizational cultural humility and hospital safety culture. Higher perceptions of organizational cultural humility were associated with higher levels of general perceptions of hospital safety, as well as more positive ratings on non-punitive response to error (i.e., mistakes of staff are not held against them), handoffs and transitions, and organizational learning. The cultural humility of one's organization may be an important factor to help improve hospital safety culture. We conclude by discussing potential directions for future research.

A Novel Strategy to Increase Identification of African-Born People With Chronic Hepatitis B Virus Infection in the Chicago Metropolitan Area, 2012-2014

INTRODUCTION

Most research on hepatitis B virus (HBV) infection in the United States is limited to Asian populations, despite an equally high prevalence among African immigrants. The purpose of this study was to determine testing and detection rates of HBV infection among African-born people residing in the Chicago metropolitan area.

METHODS

A hepatitis education and prevention program was developed in collaboration with academic, clinical, and community partners for immigrant and refugee populations at risk for HBV infection. Community health workers implemented chain referral sampling, a novel strategy for recruiting hard-to-reach participants, targeting African-born participants. Participants were tested in both clinical and nonclinical settings. To assess infection status, blood samples were obtained for hepatitis B surface antigen (HBsAg), core antibody, and surface antibody testing. Demographic information was collected on age, sex, health insurance status, country of origin, and years residing in the United States. Participants were notified of testing results, and HBsAg-positive participants were referred for follow-up medical care.

RESULTS

Of 1,000 African-born people who received education, 445 (45%) agreed to participate in HBV screening. There were 386 (87%) participants tested in clinical and 59 (13%) tested in nonclinical sites. Compared with participants who were tested in clinical settings, participants tested in nonclinical settings were older, were less likely to have health insurance, and had lived in the United States longer (P < .005 for each). Of these, most were from the Democratic Republic of the Congo (14%), Nigeria (13%), Ghana (11%), Somalia (11%), or Ethiopia (10%). There were 35 (8%) HBsAg-positive people, 37% had evidence of past infection, and 29% were immune.

CONCLUSIONS

Chain referral sampling identified many at-risk African-born people with chronic HBV infection. The large proportion of HBsAg-positive people in this sample reinforces the need for health promotion programs that are culturally appropriate and community-driven.

Determinants of individuals' participation in integrated chronic disease screening in Singapore

BACKGROUND

A large pool of patients with chronic diseases remains undiagnosed globally and in Singapore. We explored factors associated with participation in a health screening exercise, using revealed preference, that is, actual attendance, to understand why people remain undiagnosed with chronic diseases.

METHODS

A cross-sectional, community-based sample of Singapore residents was invited to participate in home interviews, and subsequently to attend centre-based health screening, between 2004 and 2007. Determinants of health screening participation were identified using logistic regression models based on Andersen's Behavioral Model.

RESULTS

Of the 6366 participants who completed health interview, 4092 attended the health screening, while 2274 did not. Older age, Chinese or Indian ethnicity, higher education levels, greater intake of monounsaturated fat, greater transport and leisure-time physical activity were the key predisposing factors associated with greater health screening participation. Greater family cohesion was the key associated enabling factor, while previous diagnosis of dyslipidaemia or musculoskeletal conditions, absence of previously diagnosed diabetes or hypertension and lower perceived physical health were the associated need factors.

CONCLUSIONS

Our study suggests that ethnicity, education, family cohesion, healthy behaviour patterns and perceived physical health status were key determinants of health screening participation. Enhancing the cultural competence of preventive health services may help increase participation of these groups in screening efforts and reduce the proportions of undiagnosed chronic disease in the community.

A Cross Sectional and Longitudinal Study of Pharmacy Student Perceptions of Readiness to Serve Diverse Populations

Objective. To examine students' self-perceptions at different stages in a pharmacy curriculum of competence related to serving culturally diverse patients and to compare self-reported competence of a student cohort near the beginning and end of the degree program. Methods. Student perceptions across four pharmacy class years were measured in a cross-sectional survey, with a follow-up longitudinal survey of one cohort three years later. Results. Based on an 81.9% response rate (537/656), scores showed no attitude changes. Reported knowledge, skills, comfort in clinical encounters, and curricular preparedness increased across program years. Fourth-year (P4) pharmacy students reported the highest scores. Scores differed by gender, age, and race/ethnicity. Students in the fourth year scored lower on importance of diversity training. Conclusion. Improved perceptions of readiness (ie, knowledge and behavior) to serve diverse groups suggest the curriculum impacts these constructs, while the invariance of student attitudes and association of self-reports with programmatic outcomes warrant further investigation.

Guidelines for Teaching Cross-Cultural Clinical Ethics: Critiquing Ideology and Confronting Power in the Service of a Principles-Based Pedagogy

This paper presents a pedagogical framework for teaching cross-cultural clinical ethics. The approach, offered at the intersection of anthropology and bioethics, is innovative in that it takes on the "social sciences versus bioethics" debate that has been ongoing in North America for three decades. The argument is made that this debate is flawed on both sides and, moreover, that the application of cross-cultural thinking to clinical ethics requires using the tools of the social sciences (such as the critique of the universality of the Euro-American construct of "autonomy") within (rather than in opposition to) a principles-based framework for clinical ethics. This paper introduces the curriculum and provides guidelines for how to teach cross-cultural clinical ethics. The learning points that are introduced emphasize culture in its relation to power and underscore the importance of viewing both biomedicine and bioethics as culturally constructed.

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.

Cultural Competence in Pediatrics: Health Care Provider Knowledge, Awareness, and Skills

The purpose of this study was to assess the effects of a cultural competence training (CCT) program on pediatric health care providers' self-reported ability to provide culturally competent care to a diverse pediatric patient population. This quantitative, nested ecologic level study design used a repeated measure in the form of pre-test and post-test data to assess percent change in providers' cultural awareness, experience working or learning about different cultures, and preparedness and skills in working with different cultures before and after CCT. The study was conducted between 2011 and 2012 in a pediatric hospital and associated outpatient offices. The sample consisted of pediatric health care providers from various departments, mainly physicians and nurses (n = 69). Participants completed a pre-intervention cultural competence assessment and then were subjected to a cultural competence-training program, after which they completed the assessment a second time. The baseline and post-intervention data were collected in the form of Likert scales and transformed into a quintile or quartile scale as appropriate. Data were assessed using paired t-tests or Wilcoxon's signed-rank tests. Providers indicated a 13% increase in knowledge (53.9% vs. 66.7%, t = 3.4, p = 0.001), 8.7% increase in awareness (46.7% vs. 55.4%, t = 3.0, p = 0.002), and 8% statistically marginal increase in skills (66.4% vs. 74.5%, z = 1.8, p = 0.06). Culturally competent training in a pediatric environment significantly enhances knowledge, awareness and to some extent skills in providing care to culturally diverse patient population.

Intercultural Competency in Public Health: A Call for Action to Incorporate Training into Public Health Education

Due to increasing national diversity, programs addressing cultural competence have multiplied in U.S. medical training institutions. Although these programs share common goals for improving clinical care for patients and reducing health disparities, there is little standardization across programs. Furthermore, little progress has been made to translate cultural competency training from the clinical setting into the public health setting where the focus is on population-based health, preventative programming, and epidemiological and behavioral research. The need for culturally relevant public health programming and culturally sensitive public health research is more critical than ever. Awareness of differing cultures needs to be included in all processes of planning, implementation and evaluation. By focusing on community-based health program planning and research, cultural competence implies that it is possible for public health professionals to completely know another culture, whereas intercultural competence implies it is a dual-sided process. Public health professionals need a commitment toward intercultural competence and skills that demonstrate flexibility, openness, and self-reflection so that cultural learning is possible. In this article, the authors recommend a number of elements to develop, adapt, and strengthen intercultural competence education in public health educational institutions.

Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) Perceptions and Health Care Experiences

BACKGROUND

The goal study of this was to explore attitudes, health knowledge, and experiences with healthcare setting and providers among gay, lesbian, bisexual, transgender, queer/questioning (GLBTQ) individuals and to identify areas for improvement.

METHODS

Members of Equality Florida™ residing in the five counties of the Tampa Bay region were recruited through email invitation to complete a 60-item questionnaire assessing demographics, attitudes, and experiences with healthcare providers (HCPs). Additional open-ended questions focused on experiences with HCPs and suggestions for ways to improve HCPs' cultural competency.

RESULTS

632 respondents completed the survey of which 41% were gay men and 29% were lesbian. The majority of participants was White, non-Hispanic (93%), married/partnered (78%), and had health insurance (88%). The majority (67%) reported they always or often disclosed their sexual orientation/identity to an HCP and few had negative reactions in the healthcare setting (<10%). Healthcare settings with equality signs and gender-neutral language were perceived as safer. Participants' responses suggested need for policy changes and improved cultural competence among HCPs.

CONCLUSION

Results show high rates of sexual orientation disclosure, greater acceptance from providers of GLBTQ status, and the need for examination of hospital policies and improved cultural competency.

Delivering a "dose of hope": a faith-based program to increase older african americans' participation in clinical trials

BACKGROUND

Underrepresentation of older-age racial and ethnic minorities in clinical research is a significant barrier to health in the United States, as it impedes medical research advancement of effective preventive and therapeutic strategies.

OBJECTIVE

The objective of the study was to develop and test the feasibility of a community-developed faith-based intervention and evaluate its potential to increase the number of older African Americans in clinical research.

METHODS

Using a cluster-randomized design, we worked with six matched churches to enroll at least 210 persons. We provided those in the intervention group churches with three educational sessions on the role of clinical trials in addressing health disparity topics, and those in the comparison group completed surveys at the same timepoints. All persons enrolled in the study received ongoing information via newsletters and direct outreach on an array of clinical studies seeking participants. We evaluated the short-, mid-, and longer-term effects of the interventional program on clinical trial-related outcomes (ie, screening and enrollment).

RESULTS

From 2012 to 2013, we enrolled a balanced cohort of 221 persons in the program. At a 3-month follow-up, mean intention to seek information about clinical trials was higher than baseline in both treatment (mu=7.5/10; sigma=3.1) and control arms (mu=6.6/10; sigma=3.3), with the difference more pronounced in the treatment arm. The program demonstrated strong retention at 3-month (95.4%, 211/221) and 6-month timepoints (94.1%, 208/221).

CONCLUSIONS

The "Dose of Hope" program addressed an unmet need to reach an often overlooked audience of older African Americans who are members of churches and stimulate their interest in clinical trial participation. The program demonstrated its appeal in the delivery of effective messages and information about health disparities, and the role of clinical research in addressing these challenges.

Perceived Safety, Quality and Cultural Competency of Maternity Care for Culturally and Linguistically Diverse Women in Queensland

Various policies, plans and initiatives have been implemented to provide safe, quality and culturally competent care to patients within Queensland's health care system. A series of models of maternity care are available in Queensland that range from standard public care to private midwifery care. The current study aimed to determine whether identifying as culturally or linguistically diverse (CALD) was associated with the perceived safety, quality and cultural competency of maternity care from a consumer perspective, and to identify specific needs and preferences of CALD maternity care consumers. Secondary analysis of data collected in the Having a Baby in Queensland Survey 2012 was used to compare the experiences of 655 CALD women to those of 4049 non-CALD women in Queensland, Australia, across three stages of maternity care: pregnancy, labour and birth, and after birth. After adjustment for model of maternity care received and socio-demographic characteristics, CALD women were significantly more likely than non-CALD women to experience suboptimal staff technical competence in pregnancy, overall perceived safety in pregnancy and labour/birth, and interpersonal sensitivity in pregnancy and labour/birth. Approximately 50 % of CALD women did not have the choice to use a translator or interpreter, or the gender of their care provider, during labour and birth. Thirteen themes of preferences and needs of CALD maternity care consumers based on ethnicity, cultural beliefs, or traditions were identified; however, these were rarely met. Findings imply that CALD women in Queensland experience disadvantageous maternity care with regards to perceived staff technical competence, safety, and interpersonal sensitivity, and receive care that lacks cultural competence. Improved access to support persons, continuity and choice of carer, and staff availability and training is recommended.

Do Experiences with Medicare Managed Care Vary According to the Proportion of Same-Race/Ethnicity/Language Individuals Enrolled in One's Contract?

OBJECTIVE

To examine whether care experiences and immunization for racial/ethnic/language minority Medicare beneficiaries vary with the proportion of same-group beneficiaries in Medicare Advantage (MA) contracts.

DATA SOURCES/STUDY SETTING

Exactly 492,495 Medicare beneficiaries responding to the 2008-2009 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey.

DATA COLLECTION/EXTRACTION METHODS

Mixed-effect regression models predicted eight CAHPS patient experience measures from self-reported race/ethnicity/language preference at individual and contract levels, beneficiary-level case-mix adjustors, along with contract and geographic random effects.

PRINCIPAL FINDINGS

As a contract's proportion of a given minority group increased, overall and non-Hispanic, white patient experiences were poorer on average; for the minority group in question, however, high-minority plans may score as well as low-minority plans. Spanish-preferring Hispanic beneficiaries also experience smaller disparities relative to non-Hispanic whites in plans with higher Spanish-preferring proportions.

CONCLUSIONS

The tendency for high-minority contracts to provide less positive patient experiences for others in the contract, but similar or even more positive patient experiences for concentrated minority group beneficiaries, may reflect cultural competency, particularly language services, that partially or fully counterbalance the poorer overall quality of these contracts. For some beneficiaries, experiences may be just as positive in some high-minority plans with low overall scores as in plans with higher overall scores.

Assessing cultural competency skills in gastroenterology fellowship training

AIM: To assess and teach cultural competency skills at the fellowship training level through the use of objective structured clinical examinations (OSCEs).

METHODS: We revised four scenarios to infuse a specific focus on cross-cultural care, and to render them appropriate for gastroenterology fellows. Three are discussed here: (1) Poor Health Literacy; (2) Disclosing/Apologizing for a Complication to a Patient Who Mistrusts the Healthcare System; and (3) Breaking Bad News to a Fatalistic Patient. A fourth case emphasizing shared decision-making will be described elsewhere. Four stations were completed by fellows and observed live by four faculty members, and the fellows’ performance was assessed.

RESULTS: Eleven fellows from four programs participated in the four OSCE. In the “Poor Health Literacy” case, 18% (2/11) of participants recognized that the standardized patient (SP) had below-basic health literacy. None successfully evaluated the SP’s reading skills in a culturally-sensitive manner. In “Disclosing/Apologizing for a Complication”, 4/11 (36%) personally apologized for the complication. 1/11 recognized the SP’s mistrust of the medical system. With “Breaking Bad News”, 27% (3/11) explored the patient’s values to identify her fatalistic beliefs.

CONCLUSION: OSCEs can be used to assess deficiencies in culturally-competent care at the fellowship level. OSCEs also afford fellowships the opportunity to inform future training curricula.

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

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

APPROACH

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

FINDINGS

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

Comparing the implementation of team approaches for improving diabetes care in community health centers

BACKGROUND

Patient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients.

METHODS

Mixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources.

RESULTS

Implementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth.

CONCLUSION

Implementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities.

A snapshot of patients' perceptions of oncology providers' cultural competence

In this paper, we describe an anonymous cross-sectional survey with a sample of 100 racially diverse adult oncology patients using a newly developed patient-reported measure of providers' cultural competence, the Physicians' Cultural Competence for Patient Satisfaction Scale (PCCPS) [1, 2], which was developed using a US midwestern sample of primary care patients. Our primary aims were to examine the reliability of the PCCPS in a more racially diverse urban oncology clinical setting and to identify salient domains of oncology provider cultural competence based on patient-reported satisfaction with direct clinical encounters. Results suggest that patient-reported satisfaction was significantly associated with one of the four domains measured by the PCCPS, physician's patient-centered cultural competence (r = 0.40, p = 0.01), and female patients were more satisfied (t (91) = 5.23, p = 0.02). The PCCPS demonstrated good reliability in an urban diverse cancer patient population. Results help to inform the development of clinical tools that can improve oncology providers' cultural competency.

Using a cultural formulation for assessment of homicide in forensic psychiatry in the UK

Healthcare inequalities for black and minority ethnic (BME) patients in forensic mental health services in the UK are stark. Despite the level of attention given to this over the last 15 years there has been little progress to address disparities. There is a great deal of confusion over what is understood by culture, and what aspects of culture signal specific needs of BME patients. In addition, we have a lack of empirical research demonstrating what it means for psychiatrists to be culturally competent. These are all important barriers against progress in this area. Using a homicide case study that illustrates the typical issues encountered in practice, we explore how to use a cultural formulation in order to assess the role of culture within a forensic psychiatry setting. Finally, practical advice is offered to assist expert witnesses in preparing court reports that adequately consider the significance of defendants' cultural beliefs and practices.

As I see it: a study of African American pastors' views on health and health education in the black church

The Black Church is the only institution that has consistently served the interest of African Americans, and there is no other institution in the African American community that rivals its influence (Camara, 2004). The spiritual well-fare, social support, health, and well-being of its people have been one of its main goals. With health disparities of African Americans still at an alarming rate, the Black Church has used informal education as a means to impart knowledge on health, as well as other non-religious and religious topics. One of the avenues least researched within the Black Church is the pastor's perception of its educational role in health and wellness and its efforts to reduce health discrimination and health disparities between African American and European Americans in the U.S. Since social justice appears as a theme and concern in the traditions of many churches, it is only appropriate that, among other things, the Black Church should address the issue of health education and interventions. The purpose of this study was to explore African American pastors' perceptions of the role of the Black Church in providing health care, health education, and wellness opportunities to African Americans. Many pastors reported their church provided some form of health education and/or health screenings. Their perceptions about the important issues facing their congregants versus African Americans in general were quite similar.

Adaptation of health care for migrants: whose responsibility?

BACKGROUND

In a context of increasing ethnic diversity, culturally competent strategies have been recommended to improve care quality and access to health care for ethnic minorities and migrants; their implementation by health professionals, however, has remained patchy. Most programs of cultural competence assume that health professionals accept that they have a responsibility to adapt to migrants, but this assumption has often remained at the level of theory. In this paper, we surveyed health professionals' views on their responsibility to adapt.

METHODS

Five hundred-and-sixty-nine health professionals from twenty-four inpatient and outpatient health services were selected according to their geographic location. All health care professionals were requested to complete a questionnaire about who should adapt to ethnic diversity: health professionals or patients. After a factorial analysis to identify the underlying responsibility dimensions, we performed a multilevel regression model in order to investigate individual and service covariates of responsibility attribution.

RESULTS

Three dimensions emerged from the factor analysis: responsibility for the adaptation of communication, responsibility for the adaptation to the negotiation of values, and responsibility for the adaptation to health beliefs. Our results showed that the sense of responsibility for the adaptation of health care depended on the nature of the adaptation required: when the adaptation directly concerned communication with the patient, health professionals declared that they should be the ones to adapt; in relation to cultural preferences, however, the responsibility felt on the patient's shoulders. Most respondents were unclear in relation to adaptation to health beliefs. Regression indicated that being Belgian, not being a physician, and working in a primary-care service were associated with placing the burden of responsibility on the patient.

CONCLUSIONS

Health care professionals do not consider it to be their responsibility to adapt to ethnic diversity. If health professionals do not feel a responsibility to adapt, they are less likely to be involved in culturally competent health care.

How we developed a locally focused Global Health Clinical Preceptorship at Weill Cornell Medical College

BACKGROUND

Global health educational programs within U.S. medical schools have the opportunity to link their "global" focus with local circumstances by examining the challenges underserved communities face in the United States.

AIM

Students in Weill Cornell Medical College's Global Health Clinical Preceptorship (GHCP) learn history-taking and physical examination skills while gaining exposure to local health care disparities and building cultural competency.

METHODS

First-year medical students in the program are placed in the office of a physician who works with underserved patient populations in New York City. Students receive an orientation session, shadow their preceptors one afternoon per week for seven weeks, complete weekly readings and assignments on topics specific to underserved populations, attend a reflection session, and write a reflection paper.

RESULTS

In three years, 36% of first-year students (112 of 311) opted into the elective GHCP program. Students reported gaining a better understanding of the needs of underserved patient populations, being exposed to new languages and issues of cultural competency, and having the opportunity to work with role model clinicians.

CONCLUSIONS

The GHCP is a successful example of how global health programs within medical schools can incorporate a domestic learning component into their curricula.

Low-income cancer patients in depression treatment: dropouts and completers

This study aims to explore reasons for depression treatment dropout among low-income, minority women with depression and cancer. Semi-structured telephone interviews are conducted with 20, predominately Latina, patients who dropped out of depression treatment and 10 who completed. Transcripts analyzed using techniques rooted in grounded theory. Treatment completion barriers cluster according to Meichenbaum and Turk's (Facilitating treatment adherence: A practitioner's guidebook, Plenum Press, New York, 1987) five adherence dimensions: (a) Barriers to Treatment (informational, instrumental, cultural [language, discrimination]); (b) Disease Features (emotional burden of cancer/depression); (c) Cancer/Depression Treatment Regimens; (d) Provider-Patient Relationship (depression treatment dissatisfaction); and (e) Clinical Setting (hospital organizational issues). Although both groups describe multiple overlapping dimensions of barriers, completers seem more motivated and satisfied with treatment, possibly due to completers experiencing the positive treatment effects after the first several sessions. More research should be conducted to determine the most effective clinical treatment methods for this population.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

The role of collaboration in facilitating policy change in youth violence prevention: a review of the literature

Youth violence remains a serious public health issue nationally and internationally. The social ecological model has been recommended as a framework to design youth violence prevention initiatives, requiring interventions at the micro-, meso-, exo-, and macro-levels. However, documentation of interventions at the macro-level, particularly those that address policy issues, is limited. This study examines a recommendation in the literature that formalized collaborations play a vital role in stimulating macro-level policy change. The purpose of this systematic literature review is to examine existing youth violence prevention collaborations and evaluate their policy-related outcomes. The search found 23 unique collaborations focused on youth violence prevention. These were organized into three groups based on the "catalyst" for action for the collaboration-internal (momentum began within the community), external (sparked by an external agency), or policy (mandated by law). Findings suggest that internally catalyzed collaborations were most successful at changing laws to address youth violence, while both internally and externally catalyzed collaborations successfully attained policy change at the organizational level. A conceptual model is proposed, describing a potential pathway for achieving macro-level change via collaboration. Recommendations for future research and practice are suggested, including expansion of this study to capture additional collaborations, investigation of macro-level changes with a primary prevention focus, and improvement of evaluation, dissemination, and translation of macro-level initiatives.

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.

Cultural identity and patient trust among older American Indians

BACKGROUND

Patients' trust in healthcare providers and institutions has been identified as a likely contributor to racial-ethnic health disparities. The likely influence of patients' cultural characteristics on trust is widely acknowledged but inadequately explored.

OBJECTIVE

To compare levels of patients' trust in primary care provider (interpersonal trust) with trust in healthcare organizations (institutional trust) among older American Indians (AIs), and determine associations with cultural identity.

DESIGN

Patient survey administered following primary care visits.

PARTICIPANTS

Two-hundred and nineteen American Indian patients ≥ 50 years receiving care for a non-acute condition at two clinics operated by the Cherokee Nation in northeastern Oklahoma.

MAIN MEASURES

Self-reported sociodemographic and cultural characteristics. Trust was measured using three questions about interpersonal trust and one measure of institutional trust; responses ranged from strongly agree to strongly disagree. Finding substantial variation only in institutional trust, we used logistic generalized estimating equations to examine relationships of patient cultural identity with institutional trust.

KEY RESULTS

Ninety-five percent of patients reported trusting their individual provider, while only 46 % reported trusting their healthcare institution. Patients who strongly self-identified with an AI cultural identity had significantly lower institutional trust compared to those self-identifying less strongly (OR: 0.6, 95 % CI: 0.4, 0.9).

CONCLUSIONS

Interpersonal and institutional trust represent distinct dimensions of patients' experience of care that may show important relationships to patients' cultural characteristics. Strategies for addressing low institutional trust may have special relevance for patients who identify strongly with AI culture.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How Does Satisfaction With Medical Care Differ by Citizenship and Nativity Status?: A County-Level Multilevel Analysis

PURPOSE OF THE STUDY

This study examined patient satisfaction among community-dwelling older adults by their citizenship and nativity statuses. Since the welfare reform of 1996, citizenship has been an important factor in determining health care access among foreign-born individuals. Little is known regarding how the perceived satisfaction of older noncitizens compares with that of U.S.-born and naturalized citizens and how it is affected by county-level contextual characteristics.

DESIGN AND METHODS

The 2000-2007 Medical Expenditure Panel Survey and linked Area Resource File were analyzed for 27,383 individuals (65+). Two dimensions of satisfaction (perceived access and ease of access) were examined using the Consumer Assessment of Health Plans Survey. Multilevel models were conducted using STATA.

RESULTS

After both individual- and county-level covariates were controlled for, noncitizens were less likely to agree that their providers had spent enough time with them (p = .03) or had sufficiently explained treatment (p = .01) compared with U.S.-born citizens. Noncitizens' overall ratings of their providers were also lower (p < .001). Among those reported needs, noncitizens reported greater difficulties in accessing acute care (p < .001), routine care (p < .001), and specialty care (p = .009). In these models, some county-level characteristics (e.g., % of foreign-born individuals) were negatively associated with individual-level satisfaction. Interestingly, noncitizens from counties with high densities of foreign-born populations had higher overall satisfaction levels than did their U.S.-born counterparts (i.e., interaction effect).

IMPLICATIONS

Guided by the expanded Andersen model, this study demonstrates the importance of considering both individual- and county-level contextual characteristics to accurately understand older noncitizens' access to health care and patient satisfaction.

Concept Analysis of Culture Applied to Nursing

Culture is an important concept, especially when applied to nursing. A concept analysis of culture is essential to understanding the meaning of the word. This article applies Rodgers’ (2000) concept analysis template and provides a definition of the word culture as it applies to nursing practice. This article supplies examples of the concept of culture to aid the reader in understanding its application to nursing and includes a case study demonstrating components of culture that must be respected and included when providing health 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.