Rethinking Cultural Competence: Shifting to Cultural Humility

Towards addressing the awarding gap-Using critical race theory to contextualise the role of intersectionality in Black pharmacy student attainment

INTRODUCTION

The awarding gap between White and Black students in UK health curricula is well established. Critical race theory (CRT) is a lens to deconstruct pedagogic practice and consider the intersectionality of Black student lived experience to provide a realist critique of the phenomenon of Whiteness in higher education and the impact this has on Black attainment. Using one UK pharmacy programme as a case study, this paper aims to explore Black lived experience as a means of problematising and disrupting structural oppressions.

METHODS

Sixteen Black students from one UK pharmacy degree programme were purposively recruited to the study. Love and breakup letter methodology (LBM) was used to facilitate sharing experiences of intersectionality in relation to their undergraduate education, with data thematically analysed through the lens of CRT.

RESULTS

Two meta-themes (identity and inclusion; and cultural capital) and four subthemes (social capital; access; family expectations; and help-seeking) were identified. The intersectionality of Black students was articulated as not possessing the social capital and the 'language' to succeed within the White structures of the curriculum. The conflict of capital and the absence of Black culture gave rise to confined help-seeking behaviours. Whilst Black students experienced equality of access to the curriculum, an absence of rights to legitimate involvement (inclusion) worked to diminish participation in the curriculum.

DISCUSSION

This is the first study to consider the intersectionality of Black pharmacy students in relation to academic awarding gaps and has found that oppressive educational structures marginalise and other Black experience. Black students experience the curriculum as a place where their social and cultural capital is undervalued, and as a White space where they lack the artefacts to succeed, leading to peripheral participation and detachment. The approach used in this study can be adopted across medical and health education as a means to problematise racial inequality through the exemplar of White:Black awarding gaps.

Family Involvement in Routine Services for Individuals With Severe Mental Illness: Scoping Review of Barriers and Strategies

OBJECTIVE

The authors investigated barriers to practices that promote family involvement in mental health services, focusing on individuals with severe mental illness, their families, and mental health providers. Additionally, the authors sought to identify strategies to facilitate family involvement in mental health provision to highlight the engagement process in routine practice and propose future directions for organizations to establish a family-friendly environment.

METHODS

Systematic searches for literature published from January 1990 to March 2023 were conducted in PsycInfo, PubMed, CINAHL, Sociological Abstracts, and Scopus databases. Gray literature searches and backward and forward snowballing strategies were also used.

RESULTS

Forty-six articles were reviewed, revealing contextual backgrounds and engagement practices that hindered family involvement. Inconsistencies in family involvement stemmed from organizational culture, societal attitudes, and providers' negating of family expertise. Uncertainty regarding confidentiality policies and the absence of practice guidelines posed challenges for providers. Negative experiences of families within the mental health system along with variable commitment also hampered involvement. Some service users declined family involvement because of privacy concerns and differing expectations regarding the extent of involvement. Promoting a shared culture of family work, integrating practice standards, and engaging in professional development activities emerged as key strategies.

CONCLUSIONS

A gap exists between implementing policies and practices for family involvement in mental health treatment. Without cultural and organizational shifts in support of working with families, the uptake of family involvement practices will remain inadequate. Each stakeholder has different perceptions of the barriers to family involvement, and family involvement will remain elusive without a shared agreement on its importance.

Integrating Cultural Humility into Medical Education Using a Structured and Interactive Workshop

Background

Cultural humility is a lifelong commitment to self-evaluation, redressing power imbalances in patient-physician relationships and developing mutually trusting beneficial partnerships.

Objective

The objective of this study was to determine the feasibility and efficacy of cultural humility training.

Methods

From July 2020-March 2021, 90-minute educational workshops attended by 133 medical students, resident physicians and medical education faculty included 1) pre- and post- intervention surveys; 2) interactive presentation on equity and cultural humility principles; 3) participants explored sociocultural identities and power; and 4) reflective group discussions.

Results

There were significant increases from pre to post intervention assessments for perception scores (3.89 [SEM= 0.04] versus 4.22 [0.08], p<0.001) and knowledge scores (0.52 [0.02] versus 0.67 [0.02], p<0.001). Commonest identities participants recognized as changing over time were personality = 40%, appearance = 36%, and age =35%. Commonest identities experienced as oppressed/subjugated were race/ethnicity = 54%, gender = 40% and religion = 28%; whilst commonest identities experienced as privileged were gender= 49%, race/ethnicity = 42% and appearance= 25%. Male participants assigned mean power score of 73% to gender identity compared to mean power score of -8% by female participants (P<0.001). Non-Hispanic Whites had mean power score for race identity of 62% compared to 13% for non-white participants (p<0.001). English as a second language was only acknowledged as an oppressed/subjugated identity by those born outside the United States (p<0.001).

Conclusion

An interactive educational workshop can increase participants' knowledge and perceptions regarding cultural humility. Participants can self-reflect to recognize sociocultural identities that are oppressed/subjugated or privileged.

Amplifying the voices of underrepresented speech-language pathologists: A scoping review using the transformative research paradigm

PURPOSE

To investigate the characteristics of studies that included underrepresented speech-language pathologists (SLPs) as research participants.

METHOD

A scoping review was conducted using the principles of the transformative research paradigm, which promotes the meaningful involvement and empowerment of marginalised groups. Co-production with minority SLPs was facilitated. The search strategy was run in six databases, and the transformative checklist used for analysis.

RESULT

Twenty studies were included. Bilingual and male SLPs were among the most commonly included underrepresented SLPs. Most studies were conducted in the USA (n = 16), and used survey methods. The studies provided valuable insights into the experiences and practices of underrepresented SLPs, and yielded practical solutions to foster inclusion and diversity in the profession. Most studies demonstrated a transformative potential, but the active engagement of underrepresented SLP participants in the research cycle was rarely demonstrated.

CONCLUSION

This review calls for a shift in how and why research is conducted when including underrepresented SLP participants. Through the lens of the transformative research paradigm, we can rethink the broader aim of research and the role of researchers and participants. Using research as a platform to give visibility, voice, and agency to minority groups can stimulate change and equity in the profession.

How can white parents raise anti-racist children? Introducing the routes to effective anti-racist parenting (REAP) model

In response to highly publicized instances of overt racial injustice, there has been a recent resurgence of interest and commitment to identifying processes through which anti-racist behaviors develop among White individuals. One particularly important context in which anti-racist behaviors can develop is within families and as a result of childrearing. Theories of anti-racism typically neglect the role of families and family science research typically neglects a focus on anti-racist parenting outcomes. To further research and applied work on fostering anti-racism within White families, this paper introduces a new integrative model called routes to effective anti-racist parenting (REAP). The model draws on theories from various fields, including family science and social psychology, and uses a metaphor of nurturing a plant to explain the nuanced, multi-faceted approaches to anti-racist parenting. The model incorporates factors related to the "pot" (i.e., fundamental values and structure necessary to contain more specific anti-racist skills and behaviors), "soil" (i.e., characteristics that define anti-racist commitment), "seeds" (i.e., direct transmission of anti-racism skills), and "environment" (i.e., influential external factors). Finally, we describe the intended benefits that can be reaped from this intentional approach to anti-racist parenting. The REAP model contributes to the family science literature by providing an empirically grounded theoretical model describing the roles that parents can play in children's anti-racist development.

Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users

OBJECTIVE

To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level.

DATA SOURCE AND STUDY SETTING

We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019.

STUDY DESIGN

We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender.

DATA COLLECTION/EXTRACTION METHODS

We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence.

PRINCIPAL FINDINGS

Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination.

CONCLUSIONS

We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation.

A concept of "cultural competence" among public health nurses in Japan

OBJECTIVES

To clarify the conceptual structure of "cultural competence (CC)" among Japanese public health nurses (PHNs), to enhance culturally appropriate support.

METHODS

A modified grounded theory approach (M-GTA) was used. A total of 11 municipal PHNs participated in this study. Data were collected through semistructured interviews. Interviews were audiotaped and transcribed. A comparative analysis was performed using M-GTA.

RESULT

Five categories were identified. Japanese PHNs supported foreign residents while (1) maintaining a sincere attitude with curiosity and humility toward others regarding CC; (2) deepening their realization of issues arising from awareness of one's own and other cultures; (3) developing their knowledge about clients' cultures and the surrounding environments; and (4) mastering the skills of building a relationship with clients while creating supportive systems surrounding them. As they gained more experience in supporting foreign residents, as indicated in the above categories, their cultural competence grew, allowing them to (5) gain experience while encountering individuals without holding stereotypes and prejudice.

CONCLUSIONS

The concepts of CC that emerged are based on cultural humility and are cultivated through supportive activities. The concepts identified in this study can serve as educational guidelines for health nurses and other care providers in Japan.

Advancing Health Equity Through Artificial Intelligence: An Educational Framework for Preparing Nurses in Clinical Practice and Research

The integration of artificial intelligence (AI) into health care offers the potential to enhance patient care, improve diagnostic precision, and broaden access to health-care services. Nurses, positioned at the forefront of patient care, play a pivotal role in utilizing AI to foster a more efficient and equitable health-care system. However, to fulfil this role, nurses will require education that prepares them with the necessary skills and knowledge for the effective and ethical application of AI. This article proposes a framework for nurses which includes AI principles, skills, competencies, and curriculum development focused on the practical use of AI, with an emphasis on care that aims to achieve health equity. By adopting this educational framework, nurses will be prepared to make substantial contributions to reducing health disparities and fostering a health-care system that is more efficient and equitable.

Using Simulation to Teach Gender-Affirming Care Concepts in Nursing Education

BACKGROUND

LGBTQIA+ (lesbian, gay, bisexual, trans-gender, queer or questioning, intersex, asexual), and gender-nonconforming (GNC) individuals have limited access to quality care, leading to health disparities. Lack of training and implicit bias are significant contributors to discrimination. Nursing schools must provide opportunities for student interaction with vulnerable populations, and interacting with transgender and GNC individuals during clinical experiences may be challenging.

METHOD

Simulated experiences offer opportunities for students to develop clinical competencies. Students participated in a simulation on caring for transgender and GNC populations. Students participated in a prebriefing session, viewed a simulation video, and engaged in a debriefing session. Participants completed a pre- and postsurvey to assess their knowledge and perceived confidence.

RESULTS

Students' confidence in providing gender affirming care was improved by the activity.

CONCLUSION

Students prioritize providing competent care to vulnerable populations. In-class simulation is an effective method for improving students' clinical competencies in a safe, nonjudgmental setting. [J Nurs Educ. 2024;63(4):241-246.].

Diversity, equity, and inclusivity in observational ambulatory assessment: Recommendations from two decades of Electronically Activated Recorder (EAR) research

Ambient audio sampling methods such as the Electronically Activated Recorder (EAR) have become increasingly prominent in clinical and social sciences research. These methods record snippets of naturalistically assessed audio from participants' daily lives, enabling novel observational research about the daily social interactions, identities, environments, behaviors, and speech of populations of interest. In practice, these scientific opportunities are equaled by methodological challenges: researchers' own cultural backgrounds and identities can easily and unknowingly permeate the collection, coding, analysis, and interpretation of social data from daily life. Ambient audio sampling poses unique and significant challenges to cultural humility, diversity, equity, and inclusivity (DEI) in scientific research that require systematized attention. Motivated by this observation, an international consortium of 21 researchers who have used ambient audio sampling methodologies created a workgroup with the aim of improving upon existing published guidelines. We pooled formally and informally documented challenges pertaining to DEI in ambient audio sampling from our collective experience on 40+ studies (most of which used the EAR app) in clinical and healthy populations ranging from children to older adults. This article presents our resultant recommendations and argues for the incorporation of community-engaged research methods in observational ambulatory assessment designs looking forward. We provide concrete recommendations across each stage typical of an ambient audio sampling study (recruiting and enrolling participants, developing coding systems, training coders, handling multi-linguistic participants, data analysis and interpretation, and dissemination of results) as well as guiding questions that can be used to adapt these recommendations to project-specific constraints and needs.

Cultural Humility and Diversity in Nursing Academia: Understanding History to Create a "Brave Space" Culture in the Classroom

Nursing academicians are positioned at a critical juncture to mold the future generations of nursing with the skills of cultural humility, starting with fostering humility in the classroom. The dynamic culture of nursing education, with consideration of the diversity of nursing students and faculty, commands attention before the exploration of what is taught about the culture of patients. Classroom cultural humility must become the "brave space" of nursing academia. This is possible with strategic approaches and revisiting the history of the culture of nursing education before trying to shape its future.

Advance Care Planning Among Sexual Minority Men: Sociodemographic, Health Care, and Health Status Predictors

Objectives: Advance care planning (ACP) specifies decision-making surrogates and preferences for serious illness or end-of-life medical care. ACP research has largely neglected sexual minority men (SMM), a population that experiences disparities in health care and health status. Methods: We examined formal and informal ACP among SMM ages 40+ in the Multicenter AIDS Cohort Study (N = 1,071). Results: For informal ACP (50%), younger SMM and men with past cardiovascular events had greater odds of planning; single men had lower odds of planning. For formal ACP (39%), SMM with greater socioeconomic status had greater odds of planning; SMM who were younger, of racial/ethnic minority identities, who were single or in a relationship without legal protections, and who lacked a primary care home had lower odds of planning. Discussion: Findings warrant further exploration of both informal and formal planning. More equitable, culturally-humble engagement of SMM may facilitate access, uptake, and person-centered planning.

'It's always difficult for women': an analysis of the life stories of sub-Saharan migrant women

The aim of this study was to understand the perspectives of female residents of Spain from West Africa in terms of the factors that condition their lives. Pierre Bourdieu's theory and the model of intersectionality formed the framework we used to qualitatively analyse the life stories of these women, which was complemented with life lines. The results showed us that traditional practices such as female genital mutilation and forced marriage are part of the social habitus of this group and they relate to each other through the several types of violence that occurs throughout their lives. In addition, in reference to the African community, these women were no longer African, while in terms of the Spanish community, they did not seem Spanish. At a health, political, and social level, this knowledge can help us to understand this group and to create personalised targeted interventions for them.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Cultural & Global Implications

This article is the third in a series of eight articles that comprise this special issue on family-centered early intervention for children who are deaf or hard of hearing and their families (FCEI-DHH). It highlights the origins of FCEI-DHH in Western contexts and well-resourced locations and emphasizes the role of culture(s) in shaping FCEI-DHH. This article also cautions against the direct application of the 10 FCEI-DHH Principles presented in this issue across the globe without consideration of cultural implications. Cultural perceptions of decision-making processes and persons who can be decision-makers in FCEI-DHH are explored. Deaf culture(s) and the benefits of exposure to DHH adults with diverse backgrounds are introduced. Structural inequities that impact families' access to FCEI-DHH programs/services and systems, within and among nations and regions, are noted. The need to consider the cultural influences on families is emphasized; this applies to all levels of FCEI, including the development of systems through implementation of supports.

Twelve tips for teaching culturally and socially responsive care to medical students

In recent years, discourse on topics like cultural humility, social determinants of health (SDOH), and health disparities and inequities has greatly increased in medical education as attention to their impact on health has magnified. Unfortunately, traditional medical education models may fail to optimize learning in this area. To address these complex social health issues, we must find innovative ways to engage students in an educational partnership in which they are challenged to critically think and reflect on their attitudes, role, and actions in health equity and culturally responsive care. Through reviews of existing literature coupled with our own experience with iterative implementation of a model that includes interpersonal engagement paired with individual self-directed learning, we assembled 12 tips on how to prepare diverse students to practice lifelong cultural humility and provide culturally and socially responsive care in an ever-changing social landscape.

Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care

BACKGROUND

Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population's health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings.

OBJECTIVE

To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs.

DESIGN

Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018.

PARTICIPANTS

The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City.

APPROACH

Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts.

KEY RESULTS

Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants' identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers.

CONCLUSIONS

SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients' preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization.

Embedding cultural competency and cultural humility in undergraduate pharmacist initial education and training: a qualitative exploration of pharmacy student perspectives

BACKGROUND

Emphasis has been placed upon embedding equity, diversity and inclusion within the initial education and training of healthcare professionals, like pharmacists. Yet, there remains limited understanding of how best to integrate cultural competency and cultural humility into undergraduate pharmacy student training.

AIM

This qualitative study explored the views of pharmacy students to understand perspectives on, and identify recommendations for, embedding cultural competency and cultural humility within pharmacy education and training.

METHOD

Undergraduate pharmacy students from one UK-based School of Pharmacy were invited to participate in an in-person, semi-structured interview to discuss cultural competency in the pharmacy curriculum. Interviews were conducted between November 2022 and February 2023 and were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Ethics Committee.

RESULTS

Twelve undergraduate pharmacist students, across all years of undergraduate training, were interviewed. Three themes were developed from the data, centring on: (1) recognising and reflecting on cultural competency and cultural humility; (2) gaining exposure and growing in confidence; and (3) thinking forward as a culturally competent pharmacist of the future.

CONCLUSION

These findings offer actionable recommendations to align with the updated Initial Education and Training standards from the United Kingdom (UK) pharmacy regulator, the General Pharmaceutical Council; specifically, how and when cultural competency teaching should be embedded within the undergraduate pharmacy curriculum. Future research should further explore teaching content, learning environments, and methods of assessing cultural competency.

How cultural competence is conceptualised, developed and delivered in pharmacy education: a systematic review

BACKGROUND

It is important to have a pharmacy workforce that is culturally competent to recognise a patient's health beliefs to improve medication adherence and reduce poor treatment outcomes.

AIM

This systematic review aimed to identify, critically appraise and summarise how cultural competency is conceptualised, developed and embedded in pre-qualification pharmacy education.

METHOD

Medline, Scopus, PsychInfo, Web of Knowledge, CINAHL, and Embase databases were searched for relevant papers published in English between January 2012 and December 2021, following PRISMA guidelines. Data from included papers were thematically analysed. Educational quality of papers was appraised using the GREET criteria. This systematic review was registered on PROSPERO, CRD42021295875.

RESULTS

The review included 47 papers (46 studies) with 18 papers meeting ≥ 9 points on the GREET criteria thus considered of good educational quality. Forty papers focused on educational interventions implemented to pharmacy students only, the remaining included students from different health disciplines. Half of the educational interventions focused on cultural competence in general. Most educational interventions lasted over a week and 21 were compulsory. Cultural competence conceptualisation varied; a focus on knowledge about different cultures or on culturally competent behaviours or a continuum with knowledge at one end and behaviour at the other.

CONCLUSION

There is variation in how cultural competence is embedded in pharmacy programmes, which could be a reflection of the differences in how educators conceptualised cultural competence. Further research is needed to develop a unified understanding of the meaning of cultural competence and how it can be embedded in pharmacy education.

Provider cultural competence and humility in healthcare interactions with transgender and nonbinary young adults

PURPOSE

Transgender and nonbinary (TGNB) patients experience many barriers when seeking quality healthcare services, including ineffective communication and negative relationships with their providers as well as a lack of provider competence (including knowledge, training, and experience) and humility (engagement in the process of self-reflection and self-critique) in treating TGNB individuals. The purpose of this qualitative study was to identify factors associated with cultural competence and humility that facilitate and impede effective relationships between TGNB young adults and their healthcare providers.

METHODS

Data came from individual interviews with 60 young adults aged 18 to 24 from Florida who self-identified as transgender or nonbinary. We analyzed the data using inductive thematic approaches, and a feminist perspective, to identify themes associated with patient-provider relationships.

CONCLUSIONS

We identified 4 themes related to patient-provider relationships: (1) Participants indicated effective patient-provider communication and relationships are facilitated by providers requesting and utilizing TGNB patients' correct names and personal pronouns. (2) Participant narratives conveyed their preferences that providers "follow their lead" in terms of how they described their own anatomy, reinforcing the utility of cultural humility as an approach for interactions with TGNB patients (3) Participants discussed the detrimental effects of TGNB patients having to educate their own providers about their identities and needs, suggesting clinicians' competence regarding gender diversity is paramount to fostering and maintaining patient comfort. (4) Finally, participants' responses indicated concerns regarding the confidentiality and privacy of the information they provided to their providers, suggesting a lack of trust detrimental to the process of building rapport between patients and their providers.

CLINICAL RELEVANCE

Our findings indicate balancing the use of cultural humility and cultural competence during clinical encounters with TGNB young adults can enhance patients' experiences seeking healthcare. Nursing education is often devoid of focus on caring for transgender and nonbinary persons. Additional provider training and education on approaching clinical encounters with TGNB patients with cultural humility and competence should improve patient-provider communication and relationships, leading to a higher quality of patient care.

Practicing Cultural Humility Will Achieve Recovery-oriented Mental Health Practice and Service Delivery

The authors have proposed incorporating the concept of cultural humility to achieve better recovery outcomes. While agencies have mandated staff training in cultural competence, health outcomes have not shown promising results. Given the shortcomings of cultural competence training, cultural humility is being suggested as a complementary approach. When providers adopt cultural humility into their interactions with service users, it encompasses underlying principles and values consistent with recovery-oriented practices. Cultural humility addresses power imbalances and emphasizes ongoing self-reflection and openness to interpersonal relationships. The authors believe that embracing cultural humility will promote dignity and respect, create a culture of collaboration and partnership, acknowledge the uniqueness of each individual, enhance person-centered care, and foster self-determination and autonomy. The application of a cultural humility lens can promote a recovery-oriented culture within mental health services, and it is the responsibility of providers to actively cultivate cultural humility. Overall, cultural humility presents new opportunities for practice, and its adoption may be a key factor in promoting a recovery-oriented culture within mental health services.

Speech-Language Pathologists' Preparation, Practices, and Perspectives on Serving Indigenous Families and Children

PURPOSE

With the documented educational inequities that Indigenous children experience evidenced by disproportionate representation in special education and lower graduation rates, there is a need to better understand the backgrounds, training, professional perspectives, and clinical practices of speech-language pathologists (SLPs) serving this population. Therefore, the purpose of this study was to conduct a survey with SLPs from the Mountain West and High Plains region of the United States who serve Indigenous children to understand current patterns and to inform practices that SLPs can apply in addressing educational inequities.

METHOD

SLPs from the Mountain West and High Plains completed an online survey that gathered information about background, training, professional perspectives, and clinical practices.

RESULTS

Three hundred thirty-three SLPs completed the survey. Results revealed that respondents, for the most part, understood educational disparities that Indigenous children experience, and they valued Indigenous dialects of English and Indigenous languages. Patterns in practice revealed strong reliance on standardized measures for assessment and a small percentage of respondents using bidialectal or narrative-based strategies.

CONCLUSIONS

Very few respondents had training on serving Indigenous children and families, yet they had overall awareness of educational disparities experienced by this group. Respondents reported challenges with developing relationships and overcoming access barriers. Their clinical practices were not as tailored to the language and learning needs of Indigenous children, especially when compared to practices recommended in two recent scoping reviews. The Indigenous Connectedness Framework, the abundance model, and Indigenous pedagogies are presented as ways to initiate change and meaningful engagement with Indigenous families and communities.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24100863.

The Color of Autonomy: Examining Racial Inequity in Coercive Institutional Practices

Two articles recently published in this journal identified racial inequities in routine psychiatric practice. This Open Forum discusses the need for a paradigm shift in inequities research. The two articles reviewed here, one by Shea and colleagues on racial-ethnic inequities in inpatient psychiatric civil commitment and one by Garrett and colleagues on racial-ethnic disparities in psychiatric decisional capacity consultations, are examples of the new research gaze. Four topics are identified for enhancing understanding of racism and other forms of structural exclusion in psychiatric practice: medical authority and power imbalance between providers and patients, involuntary psychiatric commitment and requests for decisional capacity consultations as strategic research events, limited use of theory, and limitations of the literature on psychiatric inequities.

REPRESENT recommendations: improving inclusion and trust in cancer early detection research

Detecting cancer early is essential to improving cancer outcomes. Minoritized groups remain underrepresented in early detection cancer research, which means that findings and interventions are not generalisable across the population, thus exacerbating disparities in cancer outcomes. In light of these challenges, this paper sets out twelve recommendations to build relations of trust and include minoritized groups in ED cancer research. The Recommendations were formulated by a range of stakeholders at the 2022 REPRESENT consensus-building workshop and are based on empirical data, including a systematic literature review and two ethnographic case studies in the US and the UK. The recommendations focus on: Long-term relationships that build trust; Sharing available resources; Inclusive and accessible communication; Harnessing community expertise; Unique risks and benefits; Compensation and support; Representative samples; Demographic data; Post-research support; Sharing results; Research training; Diversifying research teams. For each recommendation, the paper outlines the rationale, specifications for how different stakeholders may implement it, and advice for best practices. Instead of isolated recruitment, public involvement and engagement activities, the recommendations here aim to advance mutually beneficial and trusting relationships between researchers and research participants embedded in ED cancer research institutions.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Mobile homes in the land of illness: the hospitality and hostility of language in doctor-patient relations

Illness has a way of disorientating us, as if we are cast adrift in a foreign land. Like strangers in a dessert we seek oasis to recollect ourselves, find refuge and learn to build our own shelters. Using the philosophy of Levinas and Derrida, we can interpret health care providers (HCP), and the sites from which they act (e.g. hospitals), as dwelling hosts that offer hospitality to strangers in this foreign land. While often the dwellings are physical (e.g. hospitals), this is not always the case. Language represents a mobile home of refuge to the sick. Using language the HCP has built a shelter so as to dwell in the land of illness. However, while hospitality is an inviting concept, it also implies hostility. The door that opens may also be slammed shut. This article explores the paradox of the linguistic mobile home offered to patients. It highlights the power of language to construct a safe place in a strange land, but also explores the inherent violence. It ends with an exploration of the ways language can be used by HCP to assist patients to construct their own mobile shelters.

Native American Caregiver-Child Shared Book Reading Interactions: A Descriptive Study and Integrative Review

PURPOSE

This study included two parts: a descriptive study followed by an integrative review. The purpose of the study was to converge finding from the descriptive study and summarize relevant findings from existent literature to identify potential culturally responsive early language and literacy intervention strategies for Native American caregivers and their children.

METHOD

This study included a nonexperimental descriptive design and integrative review. The descriptive study analyzed the language behaviors and shared book interactions of Native American caregivers with their young children (N = 21) and included results from a caregiver teaching questionnaire. The integrative review evaluated relevant literature and identified strategies that were described in these sources. These findings were combined with the descriptive study findings to identify promising culturally consistent language and literacy strategies.

RESULTS

Caregivers' shared book behaviors were associated with caregivers' vocabulary usage and children's shared book behaviors. Caregivers reported a number of language and teaching strategies they frequently employed; this information was integrated with other sources to identify promising approaches. A total of 20 potential strategies were identified.

CONCLUSIONS

The purpose of this study was to describe potential early language and literacy strategies for Native American families. It would be impossible to develop early language interventions to meet the needs of all Native American families and children; thus, this study is a preliminary step in identifying strategies that may be culturally responsive for some families. The integrative review supported the use of shared book reading with young Native American children. Promising language and early literacy strategies included play-based strategies, teaching new words, questioning strategies, using descriptive language, and other language and interaction enhancements. The effectiveness of these strategies should be further evaluated in future research or treatment studies.

"Sometimes that Takes You Going the Extra Mile": The Role of Providers' Self-efficacy in Refugee Mental Health Services

To achieve equity for refugee patients in mental health care settings, patient-centered, trauma-informed, and cultural humility practices have gained recognition; however, the use of these practices is not well defined. The implementation process of these practices may require providers' increased self-efficacy, motivation, and cultural intelligence (CQ). Overall, this study aims to understand training needs of health care providers to be able to provide refugee patients with culturally meaningful, patient-centered, and trauma-informed care. This is an explanatory sequential mixed-methods study and surveys (n = 20) were followed by in-depth interviews (n = 7) with health care providers. The results indicate that there is a positive relationship between providers' self-efficacy and CQ. The interviews revealed three major themes including sources of self-efficacy, the importance of trust-building, and creating trauma-informed healthcare systems. The findings suggest that a trauma-informed, patient-centered training focusing on self-efficacy and CQ enhancing activities for health care providers can improve mental health services for refugee patients.

Cultural Humility Curriculum to Address Healthcare Disparities for Emergency Medicine Residents

Introduction: Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with resident-presented lectures would increase residents’ sense of cultural humility and ability to identify vulnerable populations. Methods: At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data. Results: A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar t rend. Conclusion: This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making.

Diversity among research coordinators in a pediatric emergency medicine research collaborative network

We conducted a survey study of clinical research coordinators (CRCs) at the member institutions of the Pediatric Emergency Care Applied Research Network, to determine the demographic and linguistic characteristics of CRCs around the network, and any perceived impact of those characteristics on their duties. A total of 53/74 CRCs completed the survey. Most respondents identified as "female," "white," and "not Hispanic/Latino." Most respondents felt that their race/ethnicity and their ability to speak a language other than English would positively impact recruitment. Four female respondents felt that their gender hindered their recruitment efforts and their sense of belonging within the research team.

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.

Anxiety-Related Disorders in the Context of Racism

PURPOSE OF REVIEW

The literature on racism and anxiety-related disorders, especially social anxiety, specific phobia, and generalized anxiety disorder, is notably lacking. This report aims to review recent evidence demonstrating the link between racial discrimination and various anxiety-related disorders.

RECENT FINDINGS

Anxiety-related disorders were the most significant mediator for daily discrimination and suicidal thoughts, above both depression and substance use. Further, studies showed that racial discrimination promotes posttraumatic stress and racial trauma among people of color. Systemic racism puts people of color at a higher risk for anxiety disorders than White people. Clinical case examples provide lived evidence of diverse racial and ethnic individuals suffering from anxiety-related disorders, with the development and worsening of symptoms due to racism and microaggressions. There is a prominent need for recent research on anxiety-related disorders and racism. Recommendations for clinicians and future research directions are provided. These actions are required to address bias and mental health inequities and empower people of color.

Smoking Intervention Practices in Texas Healthcare Centers with Sexual and Gender Minority Patients

Objectives

This study evaluated the use of evidence-based practices (EBPs) for smoking cessation in centers providing behavioral healthcare for patient populations that included some proportion of sexual and gender minorities (SGMs).

Methods

Healthcare providers from 75 healthcare centers across Texas serving SGMs with behavioral health needs participated in a survey assessing their center's tobacco control policies and practices.

Results

Nearly half (N = 36) of participating centers had a comprehensive tobacco-free workplace policy, 30.67% employed ≥1 tobacco treatment specialist, 73.91% employed ≥1 prescriber, 80.82% mandated screening for patient tobacco use at intake, and 57.53% provided a template for tobacco use assessments. Overall, 70.67% of providers asked patients about smoking status, 69.33% advised patients to quit, 64.00% assessed patients' interest in quitting, 58.67% assisted patients with quit attempts, and 36.00% arranged follow-up. Providers' ability to tailor interventions for special populations like SGMs ranged from very low/0 to very high/10 (M = 4.63 ± 2.59).

Conclusions

There are opportunities to improve policy implementation, standardization and usage of evidence-based interventions, and intervention tailoring within settings providing care to SGM patients in Texas to better address their tobacco use inequities.

Extending the social category label effect to stigmatized groups: Lesbian and gay people’s reactions to “homosexual” as a label

The social category label effect describes how labels influence people’s perceptions of social groups. Though the label “homosexual” versus “lesbian/gay” decreases some heterosexual people’s support for sexual minorities, it is unknown how lesbian and gay (LG) people respond to “homosexual” as a label used to describe them. Across three experiments in a largely U.S. context (Total N = 831), we examined how use of “homosexual” influenced people’s responses on psychological instruments, preferences for demographic questions, and evaluations of individuals who use “homosexual.” The use of different labels in psychological measures did not influence LG people’s responses (Study 1). However, LG people reacted less positively to “homosexual” compared to “lesbian/gay” in demographic questions and in interpersonal exchanges (Studies 2-3), whereas heterosexual people’s reactions were largely unaffected (Study 2). LG people’s more negative reactions to “homosexual” than “lesbian/gay” were partially explained by them perceiving the “homosexual” label user as less culturally competent (i.e., less inclusive, less engaged in LGBTQ activism). In this article, we make progress in new empirical territory (sexual orientation-based cues research), propose the notion of linguistic heterosexism, and discuss the sociopolitical implications of people’s language choices.

Anti-Asian Attitudes in the Context of the COVID-19 Pandemic: an Exploratory Study

Objective

The purpose of this paper was to measure if people with greater “structural literacy,” as indicated by greater awareness of racial and socioeconomic disparities in COVID-19 impact, would hold fewer negative attitudes against those perceived to be Asian in the context of the COVID-19 pandemic.

Methods

A survey was administered between April and August 2020 to participants from two longitudinal cohorts in New York State. The survey assessed anti-Asian attitudes relating to COVID-19, awareness of racial and socioeconomic disparities in COVID-19, residential location, socioeconomic status, and other demographic information. The sample included 233 Black, Latinx, and White midlife adults from urban, suburban, and rural New York neighborhoods. Multivariable regression modeling was used to assess associations between COVID-19 disparities awareness, an indicator of structural literacy, and anti-Asian attitudes, adjusting for gender, race/ethnicity, residential location, and socioeconomic disadvantage.

Results

Greater awareness of disparities in COVID-19 was associated with lower levels of anti-Asian attitudes after adjustment (adj-slope =  − 0.358, p < 0.001).

Conclusion

Greater structural literacy, as measured by awareness of socioeconomic and racial disparities in COVID-19 impact, was associated with fewer anti-Asian attitudes among Black, Latinx, and White adults.

Implications

Increasing structural literacy may reduce anti-Asian attitudes that motivate harmful acts against oppressed groups.

Applying 'cultural humility' to occupational therapy practice: a scoping review protocol

INTRODUCTION

Cultural humility is becoming increasingly important in healthcare delivery. Recognition of power imbalances between clients and healthcare providers is critical to enhancing cross-cultural interactions in healthcare delivery. While cultural humility has been broadly examined in healthcare, knowledge gaps exist regarding its application in occupational therapy (OT) practice. This scoping review protocol aims to: (1) describe the extent and nature of the published health literature on cultural humility, including concepts, descriptions and definitions and practice recommendations, (2) map the findings from objective one to OT practice using the Canadian Practice Process Framework (CPPF), and (3) conduct a consultation exercise to confirm the CPPF mapping and generate recommendations for the practice of cultural humility in OT.

METHODS AND ANALYSIS

We will search Ovid Medline, Ovid Embase, Ovid PsycINFO, Ebsco CINAHL Plus, ProQuest ASSIA, ProQuest Sociological Abstracts, ProQuest ERIC, WHO Global Index Medicus, and Web of Science databases. Published health-related literature on cultural humility will be included. There will be no restrictions on population or article type. Following deduplication on Endnote, the search results will undergo title, abstract, and full-text review by two reviewers working independently on Covidence. Extracted data will include descriptors of the article, context, population, and cultural humility. After descriptive extraction, data describing cultural humility-related content will be descriptively and interpretively analysed using an inductive thematic synthesis approach. The data will also be mapped to OT practice through deductive coding using the CPPF. Occupational therapists and clients will be consulted to further critique, interpret and validate the mapping and generate practice recommendations.

ETHICS AND DISSEMINATION

Ethics approval was not required for this scoping review protocol. We will disseminate the findings, which can enhance understanding of cultural humility in OT, facilitate cross-cultural encounters between occupational therapists and clients and improve care outcomes through publications and presentations.

Famalismo Primero and Puerta Cerrada in Self-Managing Diabetes Among Hispanics: A Qualitative Meta-Synthesis

Introduction:

Type 2 diabetes (T2D) prevalence is increasing at concerning rates for Hispanics. Researchers have attempted to understand why through quantitative or qualitative studies. This meta-synthesis examines qualitative studies concerning barriers and facilitators that Hispanics face while managing their diabetes.

Method:

Noblit and Hare’s (1988) defined method of analysis was used to synthesize 15 qualitative studies on Hispanics’ diabetes self-management.

Results:

Findings revealed two themes: (a) famalismo primero and (b) puerta cerrada, translating to family first and closed door, respectively. In famalismo primero, Hispanics with T2D prioritize family, and receive support, motivation, and knowledge from them first; puerta cerrada is tied to barriers such as cost of services and patient–provider relationships.

Discussion:

Inclusion of family in diabetes self-management provides support and motivation for Hispanics. Hispanics experience barriers to access health care that may interfere with diabetes self-management, which need to be addressed to promote health equity.

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

Background

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

Methods

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Results

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Perioperative Considerations for Person-Centered Gender-Affirming Surgery

With more than 1 million people identifying as transgender in the United States alone, the likelihood of encountering a transgender patient and their family of choice in the perioperative setting is very high. A lack of data exists to equitably inform transgender-specific issues, as well as the associated morbidity during the transgender reassignment perioperative period. Anaesthesiologists should actively acquire the knowledge and skills needed to inclusively and respectfully manage these patients and be aware of their unique physiological and psychosocial needs. The pre-operative approach includes a detailed history, focusing on the patients cross-sex hormone treatment (CSHT) regimen and associated medical conditions. An in-depth understanding of commonly used hormones such as estrogen and testosterone and their effect in the perioperative periods is essential. The physical examination should be relevant to the anatomy that is currently present while taking into consideration feminising and masculinising procedures (e.g., genioplasty, thyroid cartilage augmentation), how these interventions alter the anatomy, and potential airway complications. Laboratory results should be interpreted with care – and with expert assistance if needed - as hormone therapy might affect reference values. In addition, risk assessment tools should be used with caution since they often include sex in their scoring system but do not account for the use of CSHT. Intraoperative considerations include urethral catheter placement, drug dosing, and drug interactions that are commonly encountered in the transgender patient. Special attention should be taken in transgender females who have undergone vocal feminization, as case reports have described unexpected difficult airway management. A multimodal approach, which includes regional blocks and attention to pre-existing chronic pain conditions, should be employed as part of the post-operative pain management plan. The post-operative nausea and vomiting risk has not yet been established in this population, requiring appropriate anti-emetic prophylaxis. Despite societal advances that improve transgender health, the medical community still lacks empirical evidence to effectively mitigate the distinctive challenges confronted by this at-risk population.