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

Management of type 2 diabetes in New Zealand: a scoping review of interventions with measurable clinical outcomes

OBJECTIVE

This review aimed to assess the effectiveness of interventions for type 2 diabetes (T2D) management in New Zealand on clinical outcomes, and explore the factors impacting their feasibility and acceptability.

STUDY DESIGN

Scoping review.

METHODS

Three databases (PubMed, Web of Science and Scopus) were searched between January 2000 and July 2023. Reference lists of included studies were hand searched to identify additional articles.

RESULTS

The search yielded 550 publications, of which 11 were included in the final review. Most interventions (n = 10) focussed on education and seven were delivered by health professionals. Supporting factors for interventions included clinical/peer support (n = 8) and whānau (family) involvement (n = 6). Hindering factors included non-adherence (n = 4) and high drop-out (n = 4). Most studies reported modest improvement in HbA1c and weight at six months, but minimal change in HbA1c, weight, lipids, renal profile, and blood pressure by two years.

CONCLUSION

Future interventions should involve culturally appropriate approaches to improve engagement and acceptability while addressing lifestyle and medication adherence for T2D management. T2D interventions not widely disseminated via academic channels need to be further identified.

Psychometric Testing of the Filipino Version of the Clients' Perceptions of Providers' Cultural Competency Instrument Among LGBTQ+ Population in the Philippines

Background and Purpose: Cultural competence is significant in addressing the health needs of vulnerable populations. This study conducted psychometric testing of a cultural competency instrument in the Philippines. Methods: Brislin's translation and a cross-sectional online design were used. Exploratory factor analysis (EFA) with varimax rotation examined construct validity of the 23-item scale among 157 adult LGBTQ+ residents. The scale revealed overall reliability (α = .85) including two subscales (α = .87, α = .81, and α = .61). The EFA yielded three theoretical factorial solutions. Conclusion: The Filipino version of the instrument demonstrated reliability and validity. Measuring clients' perceptions of provider and organizational cultural competency can improve the utilization of healthcare in Filipino LGBTQ+ communities. Future research will examine the dimensional structures of the instrument among expanded LGBTQ+ communities.

A pilot study examining the impact of a pragmatic process for improving the cultural responsiveness of non-Aboriginal alcohol and other drug treatment services using routinely collected data in Australia

Objective: Routine health data has the potential to identify changes in patient-related outcomes, in close to real time. This pilot project used routine data to explore and compare the impact of changes to cultural responsiveness on service use by Aboriginal and Torres Strait Islander (hereafter, Aboriginal) clients in Australia.Methods: The New South Wales Minimum Data Set (MDS) for alcohol and other drug use treatment services was provided for 11 services for a period of 30 months from March 2019 to September 2021 (four months prior to two years after the intervention; data were analysed between March 2022 to February 2023). Change in cultural responsiveness was assessed via practice audits of services at baseline and two years. The average change in audit rating was analysed using a linear mixed regression model. Generalised Linear Mixed Models were used to identify changes in service use by Aboriginal clients. Results: All 11 services showed increased audit scores at two years, with a statistically significant mean increase of 18.6 (out of 63 points; b = 18.32, 95% CI 12.42-24.22). No statistically significant pre-to post-changes were identified in: (1) the proportion of episodes delivered to Aboriginal versus non-Aboriginal clients (OR = 1.15, 95% CI = 0.94-1.40), (2) the number of episodes of care provided to Aboriginal clients per month (IRR = 1.01, 95% CI = 0.84-1.23), or (3) the proportion of episodes completed by Aboriginal clients (OR = 0.96, 95% CI = 0.82-1.13). Conclusions: The lack of statistically significant impact on service use outcomes using MDS contrasts to the improvements in cultural responsiveness, suggesting further work is needed to identify appropriate outcome measures. This may include patient-reported experience measures. This project showed that routine data has potential as an efficient method for measuring changes in patient-related outcomes in response to health services improvements.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

DalSpace dalspace.library.dal.ca/handle/10222/80835.

Temporal trends of health disparity in the utilization of curative-intent treatments for hepatocellular carcinoma: are we making progress?

BACKGROUND

Liver-directed treatments - ablative therapy (AT), surgical resection (SR), liver transplantation (LT), and transarterial chemoembolization (TACE) - improve the overall survival of patients with early-stage hepatocellular carcinoma (HCC). Although racial and socioeconomic disparities affect access to liver-directed therapies, the temporal trends for the curative-intent treatment of HCC remain to be elucidated.

METHODS

This study performed chi-square, logistic regression, and temporal trends analyses on data from the Nationwide Inpatient Sample from 2011 to 2019. The outcome of interest was the rate of AT, SR, LT (curative-intent treatments), and TACE utilization, and the primary predictors were racial/ethnic group and socioeconomic status (SES; insurance status).

RESULTS

African American and Hispanic patients had lower odds of receiving AT (African American: odds ratio [OR], 0.78; P < .001; Hispanic: OR, 0.84; P = .005) and SR (African American: OR, 0.71; P < .001; Hispanics: OR, 0.64; P < .001) than White patients. Compared with White patients, the odds of LT was lower in African American patients (OR, 0.76; P < .001) but higher in Hispanic patients (OR, 1.25; P = .001). Low SES was associated with worse odds of AT (OR, 0.79; P = .001), SR (OR, 0.66; P < .001), and LT (OR, 0.84; P = .028) compared with high SES. Although curative-intent treatments showed significant upward temporal trends among White patients (10.6%-13.9%; P < .001) and Asian and Pacific Islander/other patients (14.4%-15.7%; P = .007), there were nonsignificant trends among African American patients (10.9%-10.1%; P = .825) or Hispanic patients (12.2%-13.7%; P = .056).

CONCLUSION

Our study demonstrated concerning disparities in the utilization of curative-intent treatment for HCC based on race/ethnicity and SES. Moreover, racial/ethnic disparities have widened rather than improved over time.

Barriers to use of interpreters in outpatient mental health care: Exploring the attitudes of psychotherapists

The support of professional interpreters is an essential component of adequate mental health care for migrants with limited language proficiency. Nevertheless, for varied reasons, only a small proportion of outpatient psychotherapists provide interpreter-mediated psychotherapy for migrants. This study explored the perspectives of psychotherapists who have not worked with professional interpreters in outpatient mental health care to identify factors that may prevent the use of interpreters in outpatient care and explore possible incentives to provide interpreter-mediated psychotherapy for migrants with limited language proficiency. Semi-structured interviews were conducted with 13 outpatient psychotherapists in Northern Germany who had not yet worked with professional interpreters in outpatient care. The interviews were audio recorded, transcribed and analysed using a structured content analysis approach. The psychotherapists named structural as well as subjective barriers and concerns. Findings suggest that improving structural factors, such as secure funding, minimal additional work, better preparation and training could facilitate the integration of professional interpreters into everyday treatment. Psychotherapists also mentioned concerns about their own confidence (e.g., insecurities regarding the triadic situation), the patient (e.g., reduced openness), the interpreter (e.g., doubts about suitability, motivation and empathy), as well as the therapeutic process (e.g., unclear allocation of roles). However, positive aspects and opportunities of interpreter-mediated psychotherapy were also described. These could be enhanced by the presence of conducive factors, such as existing trust between all parties and professional cooperation between interpreter and psychotherapist.

The Importance of Cultural Awareness in the Management of Heart Failure: A Narrative Review

Heart failure is a commonly encountered clinical syndrome arising from a range of etiologic cardiovascular diseases and manifests in a phenotypic spectrum of varying degrees of systolic and diastolic ventricular dysfunction. Those affected by this life-limiting illness are subject to an array of burdensome symptoms, poor quality of life, prognostic uncertainty, and a relatively onerous and increasingly complex treatment regimen. This condition occurs in epidemic proportions worldwide, and given the demographic trend in societal ageing, the prevalence of heart failure is only likely to increase. The marked upturn in international migration has generated other demographic changes in recent years, and it is evident that we are living and working in ever more ethnically and culturally diverse communities. Professionals treating those with heart failure are now dealing with a much more culturally disparate clinical cohort. Given that the heart failure disease trajectory is unique to each individual, these clinicians need to ensure that their proposed treatment options and responses to the inevitable crises intrinsic to this condition are in keeping with the culturally determined values, preferences, and worldviews of these patients and their families. In this narrative review, we describe the importance of cultural awareness across a range of themes relevant to heart failure management and emphasize the centrality of cultural competence as the basis of appropriate care provision.

Addressing quality medication use among migrant patients: Establishment of an organization to provide culturally competent medication care

As the global landscape continues to witness an increase in migration, the healthcare community faces an evolving challenge: the provision of quality medication care to migrant patients. Language barriers, cultural differences, and a lack of understanding of the local healthcare system can often impede the effective management of medications and access to healthcare services among migrant populations. Pharmacists, as medication experts, are dignified to make a substantial impact in bridging the gap between migrants and quality healthcare. Their expertise in medication management, accessibility, and counseling positions them as critical healthcare providers for this patient population. Pharmacies and pharmacists can serve as trusted hubs where migrants receive not only essential medications but also culturally sensitive support in navigating the healthcare system. This commentary article highlights the critical importance of culturally competent medication care for migrant patients and the central role that pharmacists can play in this endeavor. By establishing organization dedicated to this cause lead by pharmacists, we can not only address an urgent healthcare concern but also set a precedent for a healthcare system that values inclusivity, cultural competence, and equitable access to quality medication care for all, regardless of their cultural background.

Clinical yarning education: development and pilot evaluation of an education program to improve clinical communication in Aboriginal health care - participant, and health manager perspectives

BACKGROUND

Effective communication between health care clinicians and Aboriginal patients is critical to delivering high quality, accessible, culturally secure health care. Despite this, ineffective communication is a well-documented barrier, and few studies have reported interventions to improve communication. Clinical Yarning is a patient centred communication framework for Aboriginal health care. Building on this framework, this study reports the development and evaluation of a Clinical Yarning education program.

METHODS

A Clinical Yarning education program was developed, underpinned by the principles of cultural security and adult learning, informed by a behavioural skills approach. The program was delivered in five health/education settings in one rural Western Australian region. Mixed-methods evaluation included a retrospective pre/post questionnaire to ascertain changes in participants' knowledge, confidence, competence and their perceptions about communication in Aboriginal health care, and the program. Qualitative semi-structured interviews were undertaken with health service managers who oversaw each health care setting and who had not participated in the education program, to explore perceptions about the program and implementation considerations.

RESULTS

Twenty-eight health care clinicians and six students completed training and the evaluation survey. There were significant improvements in self-rated communication skills, ability, confidence, knowledge, and perceived importance of communication training from pre to post-program. Participants strongly recommended the program to others, and most commonly valued the simulation/interactive learning activities. Health service managers acknowledged the limitations in most existing cultural training, and felt Clinical Yarning addressed a need; both the concept of Clinical Yarning and the education program provided were valued. Considerations identified for future implementation included: building multilevel partnerships within health services, offering alternate training options such as eLearning or train-the-trainer approaches, and integrating into existing development programs. Workforce transiency and availability were a barrier, particularly in remote areas.

CONCLUSIONS

This study offers preliminary support for the Clinical Yarning education program and provides a foundation for further development of this training approach. A future priority is implementation research to investigate the impact of the Clinical Yarning education program on health care and patient outcomes.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

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

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

Need for integration of hepatitis C (HCV) services in community-based settings for people who inject drugs: results from a global values and preferences survey

BACKGROUND

To inform the development of updated World Health Organization (WHO) guidelines on simplified service delivery for HCV infection, a global survey was undertaken among people affected or infected by HCV. The objective of this analysis is to identify specific needs and preferences among people who inject drugs.

METHODS

A multi-country, anonymous, self-administered online survey conducted in 2021 was developed by Coalition PLUS and the World Hepatitis Alliance in partnership with the WHO. Preferences for test and treat locations and simplifying HCV care were collected among people affected or infected by HCV. Chi-square tests were used to compare respondents who identified with current or former injection drug users through identification with key population to other respondents who did not identify with this key population.

RESULTS

Among 202 respondents, 62 (30.7%) identified with current/former injection drug users. Compared to other respondents, they were: older [median (IQR): 48 (36-57) vs. 39 (31-51) years, p = 0.003]; more likely to have been tested for HCV (90.2% vs. 64.3%, p = 0.001); more likely to prefer testing in a community-based centre (CBC) (55.4% vs. 33.3%, p = 0.005); or in a support centres for people who use drugs (SCPUD)(50.0% vs. 9.8%, p < 0.001). The most important considerations regarding testing locations among people identified with current/former injection drug users (compared to the other respondents) were: non-judgemental atmosphere (p < 0.001), anonymity (p = 0.018) and community worker (CW) presence (p < 0.001). People identified with current/former injection drug users were more likely to prefer to receive HCV treatment in a CBC (63.0% vs. 44.8%, p = 0.028) or in a SCPUD (46.3% vs. 9.5%, p < 0.001), compared to the other respondents. The most important considerations regarding treatment locations among people identified with current/former injection drug users were the non-stigmatising/non-judgemental approach at the site (p < 0.001) and the presence of community-friendly medical personnel or CW (p = 0.016 and 0.002), compared to the other respondents.

CONCLUSION

The preferences of people identified with current/former injection drug users indicated specific needs concerning HCV services. Integration of HCV services in community-based risk reduction centres may be an important element in the development of adapted services to increase uptake and retention in HCV care among this population.

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.

Learning Through Diversity: Creating a Virtuous Cycle of Health Equity in Health Care Organizations

In the US, a growing number of organizations and industries are seeking to affirm their commitment to and efforts around diversity, equity, and inclusion (DEI) as recent events have increased attention to social inequities. As health care organizations are considering new ways to incorporate DEI initiatives within their workforce, the anticipated result of these efforts is a reduction in health inequities that have plagued our country for centuries. Unfortunately, there are few frameworks to guide these efforts because few successfully link organizational DEI initiatives with health equity outcomes. The purpose of this chapter is to review existing scholarship and evidence using an organizational lens to examine how health care organizations can advance DEI initiatives in the pursuit of reducing or eliminating health inequities. First, this chapter defines important terms of DEI and health equity in health care. Next, we describe the methods for our narrative review. We propose a model for understanding health care organizational activity and its impact on health inequities based in organizational learning that includes four interrelated parts: intention, action, outcomes, and learning. We summarize the existing scholarship in each of these areas and provide recommendations for enhancing future research. Across the body of knowledge in these areas, disciplinary and other silos may be the biggest barrier to knowledge creation and knowledge transfer. Moving forward, scholars and practitioners should seek to collaborate further in their respective efforts to achieve health equity by creating formalized initiatives with linkages between practice and research communities.

Mechanisms Driving Postgraduate Health and Social Science Students' Cultural Competence: An Integrated Systematic Review

PURPOSE

The COVID-19 pandemic revealed a global urgency to address health care provision disparities, which have largely been influenced by systematic racism in federal and state policies. The World Health Organization recommends educational institutions train clinicians in cultural competence (CC); however, the mechanisms and interacting social structures that influence individuals to achieve CC have received little attention. This review investigates how postgraduate health and social science education approaches CC and how it accomplishes (or not) its goals.

METHOD

The authors used critical realism and Whittemore and Knafl's methods to conduct a systematic integrated review. Seven databases (MEDLINE, CINAHL, PsycINFO, Scopus, PubMed, Web of Science, and ERIC) were searched from 2000 to 2020 for original research studies. Inclusion criteria were: the use of the term "cultural competence" and/or any one of Campinha-Bacote's 5 CC factors, being about postgraduate health and/or social science students, and being about a postgraduate curriculum or a component of it. Thematic analysis was used to reveal the mechanisms and interacting social structures underlying CC.

RESULTS

Thirty-two studies were included and 2 approaches to CC (themes) were identified. The first theme was professionalized pedagogy, which had 2 subthemes: othering and labeling. The second theme was becoming culturally competent, which had 2 subthemes: a safe CC teaching environment and social interactions that cultivate reflexivity.

CONCLUSIONS

CC conceptualizations in postgraduate health and social science education tend to view cultural differences as a problem and CC skills as a way to mitigate differences to enhance patient care. However, this generates a focus on the other, rather than a focus on the self. Future research should explore the extent to which insight, cognitive flexibility, and reflexivity, taught in safe teaching environments, are associated with increasing students' cultural safety, cultural humility, and CC.

Improving Access and Health Outcomes in Palliative Care through Cultural Competence: An exploration of opportunities and challenges in India

People who belong to ethnic, racial and cultural minorities often have less access to healthcare and have poorer health outcomes when compared to the majority population. In the COVID pandemic, too, health disparities have been observed. Similar disparities have been noted in patients with advanced disease and suffering from pain, with minority patients having less access to or making less use of palliative care. In the US, a range of solutions has been proposed to address the issue of inequality in access to healthcare, with cultural competence figuring prominently among them. This study explores whether and how cultural competence may be applied to palliative care in India to improve access and health outcomes. In the literature, it is argued that, in diverse societies, cultural competence is an essential part of the solution towards equitable healthcare systems. Solutions to problems of healthcare disparities must go beyond an increase in financial resources as more financial resources will not necessarily make the healthcare system more equitable. A culturally competent system recognises and integrates at all levels the culture as a significant component of care, which is particularly relevant at the end of life. If efficiently implemented, cultural competence will lead to higher patient satisfaction, better follow-up and patient compliance and an improved reputation of palliative care among minorities. This may help to reduce inequalities in access and health outcomes in palliative care.

Health system chief diversity officers: who are they and what do they do?

The Chief Diversity Officer, or CDO, is an increasingly common leadership role within U.S. health care delivery systems. Very little is known about the CDO role across hospitals and health systems. To map the responsibilities and characteristics of how CDOs are positioned within health care, we first searched the web pages of health systems to identify which systems have CDOs, or what we call "CDO-equivalents." Second, we expanded the search of public documents to new-hire announcements and the online social/professional media site, LinkedIn, to identify information regarding each identified leader's roles and responsibilities. Finally, text from these documents describing the leader's roles was uploaded to Atlas.ti, a qualitative analytic software, to identify common themes. There were 60 diversity leaders among 359 U.S. health care systems. Seven consistent roles and responsibilities were identified reflecting a very broad scope of work. Future research should focus on exploring the scope of this leadership role.

Organisational and staff-related effects on cultural competence in the hospital setting: a cross-sectional online survey of nursing and medical staff

Background

Cultural competence is considered a core qualification for dealing with socio-cultural diversity and balancing disparities in health care.

Objectives

To explore features supporting and inhibiting cultural competence in the hospital at both organisational and staff levels.

Design

Cross-sectional online survey in the form of a full census from May to November 2018.

Setting

Two organisations that run a total of 22 hospitals in Germany.

Participants

Eight hundred nursing and medical professionals [nurses: n = 557; doctors: n = 243].

Methods

Using the Short Form Cultural Intelligence SCALE (SFCQ), cultural competence was measured and its relation to potential influencing factors at staff level and organisational level examined, using bivariate (t-Test, one-way ANOVA, Pearson and Spearman correlations) and multivariate (multiple linear regression) approaches. Model 1 examined features at organisational level, Model 2 at individual level and Model 3 included organisational and individual features.

Results

The mean cultural competence measured was 3.49 [min.: 1.3; max.: 5.0]. In the bivariate and isolated multivariate models [Models 1 and 2], factors on both organisational and individual levels were significantly related to the hospital staff’s cultural competence. The multivariate overview [Model 3], however, revealed that individual features at staff level were the statistically relevant predictors. Positive influencing features included staff’s assessment of the importance of cultural competence in their professional context [B: 0.368, 95% confidence interval 0.307; 0.429], participation in competence training [B: 0.193; 95% confidence interval 0.112; 0.276] and having a migration background [B: 0.175; 95% confidence interval 0.074; 0.278], while negative features included length of medical service [B: -0.004; 95% confidence interval -0.007; -0.001].

Conclusions

The development and practice of cultural competence appear to be determined less by organisational features and more on the level of individual actors. In addition to staff development, adequate organisational structures and an economic incentive system are required to promote sociocultural diversity in hospitals.

'He or she maybe doesn't know there is such a thing as a review': A qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities

Introduction

Regular reviews of medications, including prescription reviews and adherence reviews, are vital to support pharmacological effectiveness and optimize health outcomes for patients. Despite being more likely to report a long‐term illness that requires medication when compared to their white counterparts, individuals from ethnic minority communities are less likely to engage with regular medication reviews, with inequalities negatively affecting their access. It is important to understand what barriers may exist that impact the access of those from ethnic minority communities and to identify measures that may act to facilitate improved service accessibility for these groups.

Methods

Semi‐structured interviews were conducted between June and August 2021 using the following formats as permitted by governmental COVID‐19 restrictions: in person, over the telephone or via video call. Perspectives on service accessibility and any associated barriers and facilitators were discussed. Interviews 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 Health Research Authority (ref: 21/HRA/1426).

Results

In total 20 participants from ethnic minority communities were interviewed; these participants included 16 UK citizens, 2 refugees and 2 asylum seekers, and represented a total of 5 different ethnic groups. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medication reviews and identified approaches to improve the accessibility of such services for ethnic minority patients. These centred on (1) building knowledge and understanding about medication reviews; (2) delivering medication review services; and (3) appreciating the lived experience of patients.

Conclusion

The results of this study have important implications for addressing inequalities that affect ethnic minority communities. Involving patients and practitioners to work collaboratively in coproduction approaches could enable better design, implementation and delivery of accessible medication review services that are culturally competent.

Patient or Public Contribution

The National Institute for Health Research Applied Research Collaboration and Patient and Public Involvement and Engagement group at Newcastle University supported the study design and conceptualization. Seven patient champions inputted to ensure that the research was conducted, and the findings were reported, with cultural sensitivity.

Sustainment of a Complex Culturally Competent Care Intervention for Hispanic Living Donor Kidney Transplantation: A Longitudinal Analysis of Adaptations

Introduction:

Sustainment refers to continued intervention delivery over time, while continuing to produce intended outcomes, often with ongoing adaptations, which are purposeful changes to the design or delivery of an intervention to improve its fit or effectiveness. The Hispanic Kidney Transplant Program (HKTP), a complex, culturally competent intervention, was implemented in two transplant programs to reduce disparities in Hispanic/Latinx living donor kidney transplant rates. This study longitudinally examined the influence of adaptations on HKTP sustainment.

Methods:

Qualitative interviews, learning collaborative calls, and telephone meetings with physicians, administrators, and staff (n = 55) were conducted over three years of implementation to identify HKTP adaptations. The Framework for Reporting Adaptations and Modifications-Expanded was used to classify adaptation types and frequency, which were compared across sites over time.

Results:

Across sites, more adaptations were made in the first year (n = 47), then fell and plateaued in the two remaining years (n = 35). Adaptations at Site-A were consistent across years (2017: n = 18, 2018: n = 17, 2019: n = 14), while Site-B made considerably fewer adaptations after the first year (2017: n = 29, 2018: n = 18, 2019: n = 21). Both sites proportionally made mostly skipping (32%), adding (20%), tweaking (20%), and substituting (16%) adaptation types. Skipping- and substituting-type adaptations were made due to institutional structural characteristics and lack of available resources, respectively. However, Site-A’s greater proportion of skipping-type adaptations was attributed to greater system complexity, and Site-B’s greater proportion of adding-type adaptation was attributed to the egalitarian team-based culture.

Conclusion:

Our findings can help prepare implementers to expect certain context-specific adaptations and preemptively avoid those that hinder sustainment.

Translation to practice of cultural safety education in nursing and midwifery: A realist review

OBJECTIVES

Health inequities exist for racial groups as a result of political, societal, historical and economic injustices, such as colonisation and racism. To address this, health professions have applied various health education pedagogies to equip learners to contribute better to cultural safety. The aim of this realist review was to provide an overview of cultural safety programs that evaluate transition of learning to practice to generate program theory as to what strategies best translate cultural safety theory to practice for nurses and midwives.

DESIGN

A systematic review following realist review publication standards.

DATA SOURCES

Nine papers were selected from six databases, from inception to January 2020. Any article that evaluated nurses and midwives practice change following participation in cultural safety education programs was included.

REVIEW METHODS

A realist review was undertaken to refine cultural safety education program theory. This involved an initial broad search of literature, research team consultation, systematic literature search with refinement of the inclusion criteria. For each included article the context, mechanism and outcomes were extracted and analysed.

RESULTS

Three program theories resulted. Firstly, system and structural leadership to drive the change process, including adoption of policy and accreditation standards and involvement of the community impacted by health inequity. Second critical pedagogy to reveal institutional and individual racist behaviours and third, nurse and midwife commitment to cultural safety.

CONCLUSION

Change in practice to achieve cultural safety is complex, requiring a multi-system approach. Cultural safety education programs adopting critical pedagogy is necessary for critical consciousness building by nurses and midwives to have impact. However, this is only one part of this interdependent change process. Involvement of those communities experiencing culturally unsafe practice is also necessary for program effectiveness. Further research is required to examine the effectiveness of coordinated multi-system approaches, alongside, nurse and midwife commitment for cultural safety.

Clinician Perspectives of Communication with Aboriginal and Torres Strait Islanders Managing Pain: Needs and Preferences

Poor communication is an important factor contributing to health disparity. This study sought to investigate clinicians’ perspectives about communicating with Aboriginal and Torres Strait Islander patients with pain. This multi-site and mixed-methods study involved clinicians from three pain management services in Queensland, Australia. Clinicians completed a survey and participated in focus groups. Clinicians rated the importance of communication training, their knowledge, ability, and confidence in communicating with Aboriginal and Torres Strait Islander patients using a 5-point Likert scale. Rating scores were combined into low (scores 1–2); moderate (score 3) and high (scores 4–5). Informed by an interpretive description methodology, thematic analysis of focus group data was used to identify the communication needs and training preferences of clinicians. Overall (N = 64), 88% of clinicians rated the importance of communication training when supporting Aboriginal and Torres Strait Islander patients as “high”. In contrast, far fewer clinicians rated as “high” their knowledge (28%), ability (25%) and confidence (28%) in effectively communicating with Aboriginal and Torres Strait Islander patients. Thematic analysis identified three areas of need: knowledge of Aboriginal and Torres Strait Islander cultures, health beliefs, and understanding cross-cultural cues. Communication skills can be learned and training, in the form of a tailored intervention to support quality engagement with Aboriginal and Torres Strait Islander patients, should combine cultural and communication aspects with biomedical knowledge.

Difficulties accessing health care services during the COVID-19 pandemic in Canada: examining the intersectionality between immigrant status and visible minority status

BACKGROUND

Difficulties accessing health care services can result in delaying in seeking and obtaining treatment. Although these difficulties are disproportionately experienced among vulnerable groups, we know very little about how the intersectionality of realities experienced by immigrants and visible minorities can impact their access to health care services since the pandemic.

METHODS

Using Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination, we combine two variables (i.e., immigrant status and visible minority status) to create a new variable called visible minority immigrant status. This multiplicative approach is commonly used in intersectionality research, which allows us to explore disadvantages experienced by minorities with multiplicative identities.

RESULTS

Main results show that, compared to white native-born, visible minority immigrants are less likely to report difficulties accessing non-emergency surgical care (OR = 0.55, p < 0.001), non-emergency diagnostic test (OR = 0.74, p < 0.01), dental care (OR = 0.71, p < 0.001), mental health care (OR = 0.77, p < 0.05), and making an appointment for rehabilitative care (OR = 0.56, p < 0.001) but more likely to report difficulties accessing emergency services/urgent care (OR = 1.46, p < 0.05).

CONCLUSION

We conclude that there is a dynamic interplay of factors operating at multiple levels to shape the impact of COVID-19 related needs to be addressed through changes in social policies, which can tackle unique struggles faced by visible minority immigrants.

Culturally safe health care practice for Indigenous Peoples in Australia: A systematic meta-ethnographic review

OBJECTIVES

Culturally safe health care services contribute to improved health outcomes for Aboriginal and Torres Strait Islander Peoples in Australia. Yet there has been no comprehensive systematic review of the literature on what constitutes culturally safe health care practice. This gap in knowledge contributes to ongoing challenges providing culturally safe health services and policy. This review explores culturally safe health care practice from the perspective of Indigenous Peoples as recipients of health care in Western high-income countries, with a specific focus on Australian Aboriginal and Torres Strait Islander Peoples.

METHODS

A systematic meta-ethnographic review of peer-reviewed literature was undertaken across five databases: Ovid MEDLINE, Scopus, PsychINFO, CINAHL Plus and Informit. Eligible studies included Aboriginal and Torres Strait Islander Peoples receiving health care in Australia, had a focus on exploring health care experiences, and a qualitative component to study design. Two authors independently determined study eligibility (5554 articles screened). Study characteristics and results were extracted and quality appraisal was conducted. Data synthesis was conducted using meta-ethnography methodology, contextualised by health care setting.

RESULTS

Thirty-four eligible studies were identified. Elements of culturally safe health care identified were inter-related and included personable two-way communication, a well-resourced Indigenous health workforce, trusting relationships and supportive health care systems that are responsive to Indigenous Peoples' cultural knowledge, beliefs and values.

CONCLUSIONS

These elements can form the basis of interventions and strategies to promote culturally safe health care practice and systems in Australia. Future cultural safety interventions need to be rigorously evaluated to explore their impact on Indigenous Peoples' satisfaction with health care and improvements in health care outcomes.

Exploring cultural competence of nurses and associated barriers in Ethiopian tertiary hospitals: A qualitative study

BACKGROUNDS

Cultural diversities in both patients and health professionals possess difficulties in cultural care. Such cultural diversities can lead to culturally inappropriate care and health disparities. Delivering culturally competent nursing care is a powerful tool to provide care equally for all patients and eliminate health disparities among culturally diverse people. The present study aimed to explore the cultural competence of nurses and associated barriers in Ethiopian tertiary hospitals.

METHODS

The study was conducted on eight purposively selected key informants from March 1 to April 30, 2018. Data was collected using semi-structured questions through face to face in-depth interview. The collected data analyzed using thematic analysis and presented in the form of text and table.

RESULTS

Eight (n = 3 females and n = 5 males) participants were involved in the study. After extensive analysis, four themes emerged: cultural competence, linguistic competence, cultural competence education and training, and barriers to cultural competence. Another six subthemes of barriers encountered by participants identified and consisted of the language barrier, trained interpreter and translator limitation, lack of knowledge of the patient's culture, lack of multicultural nursing workforce, and shortage of nursing staff, cultural and linguistic stereotypes.

CONCLUSIONS

Nurses less focused on cultural aspects of patients, and they focused more on biological factors and patients' disease. Interestingly, they expressed respect for the cultural and religious practice of patients and showed an interest to learn about cultural care nursing. Cultural competence of participants was hindered by several barriers that need nurses to overcome it.

Diversity Competency and Access to Healthcare in Hospitals in Croatia, Germany, Poland, and Slovenia

Diversity competency is an approach for improving access to healthcare for members of minority groups. It includes a commitment to institutional policies and practices aimed at the improvement of the relationship between patients and healthcare professionals. The aim of this research is to investigate whether and how such a commitment is included in internal documents of hospitals in Croatia, Germany, Poland, and Slovenia. Using the methods of documentary research and thematic analysis we examined internal documents received from hospitals in these countries. In all four countries, the documents concentrate on general statements prohibiting discrimination with regard to healthcare provision. Specific regulations concerning ethnicity and culture focus on the issue of language barriers. With regard to religious practices, the documents from Croatia, Poland, and Slovenia focus on dominant religious groups. Observance of other religious practices and customs is rarely addressed. Healthcare needs of patients with non-heteronormative sexual orientation, intersexual, and transgender patients are explicitly addressed in only a few internal documents. Diversity competency policies are not comprehensively implemented in hospital internal regulations in hospitals under investigation. There is a need for the development and implementation of comprehensive policies in hospitals aiming at the specific needs of minority groups.

Microaggression clues from social media: revealing and counteracting the suppression of women's health care

OBJECTIVE

The purpose of this study was to demonstrate how analyzing social media posts can uncover microaggressions and generate new cultural insights. We explore why Korean women hesitate to seek recommended gynecological care and how microaggressions visible in social media reveal insights for counteracting such harmful messaging.

MATERIALS AND METHODS

We scraped the posts and responses on social media related to unmarried women's uncomfortableness or unpleasantness in receiving gynecological care. We conducted content analyses of the posts and responses with the microaggression framework to identify both the types of microaggressions occurring within and outside the clinic as well as the responsible perpetrators. With an open-coding and subsequent deductive coding approach, we further investigated the socio-cultural context for receiving gynecological care as an unmarried woman in South Korea.

RESULTS

Our analysis uncovered that mothers, male partners, and superficially supportive social media responders contribute to pre- and post-visit microaggressions toward unmarried women seeking gynecological care whereas healthcare providers contribute to only mid-visit microaggressions. We also exposed how social media was not only revealing but also reinforcing the suppression of women's health care.

DISCUSSION

Mid-visit microaggressions are currently addressed by cultural competence education, but pre- and post-visit microaggressions are overlooked. We uncover the gaps in current practices of informatics and public health methods and suggest ways to counteract online and offline microaggressions.

CONCLUSIONS

Social media provides valuable information about the cultural context of health care and should be used as a source of insights for targeted interventions to improve health care, in this case for unmarried Korean women.

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

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

"Cultural Security Is an On-Going Journey…" Exploring Views from Staff Members on the Quality and Cultural Security of Services for Aboriginal Families in Western Australia

Cultural security is a key element of accessible services for Indigenous peoples globally, although few studies have examined this empirically. We explored the scope, reach, quality, and cultural security of health and social services available to Aboriginal and/or Torres Strait Islander families in Western Australia (WA), from the point of view of staff from the services. We recruited staff from health and social services for Aboriginal people in the Perth, Kalgoorlie, Great Southern, and South West regions of WA between December 2015 and September 2017 to complete online surveys. We examined the proportions of participants that responded saying the service was culturally secure, the reasons for the response, and perceived factors related to a high-quality service. Sixty participants from 21 services responded to the survey. Seventy-three percent stated the service was culturally secure; however, only 36% stated that the staff employed at the service had sufficient knowledge on cultural security. Participants suggested having Aboriginal staff and better cultural awareness training as methods to improve cultural security within the service. Participants highlighted that staffing, funding for resources, and patient financial difficulties in accessing care as key areas for quality improvement. Much greater effort is required in improving knowledge through on-going training of staff in the practice of culturally safe care. Organisations must also be required to meet specific standards in cultural safety.

Attitudes towards Immigration among Students in the First Year of a Nursing Degree at Universities in Coimbra, Toledo and Melilla

Increased migration has led to increased prejudice towards immigrant populations. This study aims to analyse attitudes towards immigration among student nurses in three universities, two in Spain and one in Portugal. Methodology: A descriptive, transversal, prospective study was carried out among student nurses (n = 624), using the Attitude towards Immigration in Nursing scale. Results: Nursing students showed some positive attitudes towards immigration, such as that immigrants should have the right to maintain their customs or that immigrants should have free access to healthcare and education, in contrast to some negative attitudes, such as that crime rates have increased due to immigration or that immigrants receive more social welfare assistance than natives. Significant differences in attitudes were revealed between students from the three universities. Discussion: Training in transcultural nursing is necessary for all nursing students in order to reduce negative attitudes towards the immigrant population and increase the awareness and sensitivity of future healthcare staff in caring for patients of all backgrounds.

Community-based health promotion about alcohol and other drugs in a multicultural Australia-what works? A review of evidence

Refugee and migrant communities from culturally and linguistically diverse backgrounds in Australia experience dependency, stigma, isolation, mental health issues, family issues and other problems associated with alcohol and other drugs. Yet, refugee and migrant communities also face major linguistic, cultural and technological barriers to health promotion about drug-related problems. The aim of this review is to identify effective techniques and approaches for health promotion that reduces the risk of problems with drugs in culturally and linguistically inclusive ways. To identify what is effective, the Medline/PubMed database was systematically searched for health promotion literature published between 2008 and 2018. Grey literature from relevant agencies was also searched. The review considered both quantitative and qualitative outcome measures, and assessed studies using the Critical Appraisal Skills Programme quality assessment tool. Three studies met inclusion criteria, with weak evaluations. The studies demonstrated effective community engagement, but do not provide conclusive evidence of what is effective drug-related health promotion. The review's findings point to an important knowledge gap. More rigorous research and evaluation are required to identify effective health promotion for reducing drug-related issues with a larger, more diverse range of refugee and migrant communities.

"How can I do more?" Cultural awareness training for hospital-based healthcare providers working with high Aboriginal caseload

BACKGROUND

Aboriginal cultural awareness training aims to build a culturally responsive workforce, however research has found the training has limited impact on the health professional's ability to provide culturally safe care. This study examined cultural awareness training feedback from healthcare professionals working with high Aboriginal patient caseloads in the Top End of the Northern Territory of Australia. The aim of the research was to assess the perception of training and the potential for expansion to better meet workforce needs.

METHODS

Audit and qualitative thematic analysis of cultural awareness training evaluation forms completed by course participants between March and October 2018. Course participants ranked seven teaching domains using five-point Likert scales (maximum summary score 35 points) and provided free-text feedback. Data were analysed using the Framework Method and assessed against Kirkpatrick's training evaluation model. Cultural safety and decolonising philosophies shaped the approach.

RESULTS

621 participants attended 27 ACAP sessions during the study period. Evaluation forms were completed by 596 (96%). The mean overall assessment score provided was 34/35 points (standard deviation 1.0, range 31-35) indicating high levels of participant satisfaction. Analysis of 683 free text comments found participants wanted more cultural education, designed and delivered by local people, which provides an opportunity to consciously explore both Aboriginal and non-Aboriginal cultures (including self-reflection). Regarding the expansion of cultural education, four major areas requiring specific attention were identified: communication, kinship, history and professional relevance. A strength of this training was the authentic personal stories shared by local Aboriginal cultural educators, reflecting community experiences and attitudes. Criticism of the current model included that too much information was delivered in one day.

CONCLUSIONS

Healthcare providers found cultural awareness training to be an invaluable entry point. Cultural education which elevates the Aboriginal health user's experience and provides health professionals with an opportunity for critical self-reflection and practical solutions for common cross-cultural clinical encounters may improve the delivery of culturally safe care. We conclude that revised models of cultural education should be developed, tested and evaluated. This requires institutional support, and recognition that cultural education can contribute to addressing systemic racism.

Increasing cultural awareness: qualitative study of nurses' perceptions about cultural competence training

BACKGROUND

Nowadays, healthcare professionals worldwide deliver care for increasing numbers of culturally and linguistically diverse patients. The importance of cultural competence is evident in terms of the quality of healthcare, and more knowledge is needed about different educational models and approaches that aim to increase cultural competence. This study examines the perceptions of nurses about the content and utility of cultural competence training that focuses on increasing awareness of one's own cultural features.

METHODS

The training was conducted at one primary care hospital in southern Finland. Participants were registered nurses (n = 14) and practical nurses (n = 6) from different hospital units. Four 4-h training sessions-including lectures, discussions and short web-based learning tasks-were arranged during a four-week period. Semi-structured, small group interviews were conducted with 10 participants to examine their perceptions about the content and utility of the training. Qualitative content analysis with a conventional approach was used to analyse the data.

RESULTS

Perceptions about the training were divided into three main categories: general utility of the training, personal utility of the training, and utility of the training for patients. General utility pertains to the general approach that the training provided on cross-cultural care, the possibility to initiate an open discussion, and the opportunity to improve current practices. Personal utility pertains to the opportunity to become aware of one's own cultural features, to change one's way of thinking, to obtain a new perspective on one's own communication practices and to receive justification for carrying out particular workable practices. Utility for patients pertains to fostering better awareness and acknowledgement of patients' differing cultural features and an increased respect in healthcare delivery. Additionally, the quality of the training was highlighted, and suggestions for improvement were offered.

CONCLUSION

Training that increases healthcare professionals' awareness of their own cultural features was perceived as useful and thought-provoking. Increased awareness might facilitate the communication between healthcare professionals and patients, which is a crucial component of quality healthcare. It seems that in the future, training opportunities that allow larger groups to participate are needed, regardless of the time and place, and utilising the potential of e-learning should be considered.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSION

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

Sex-Gender Variable: Methodological Recommendations for Increasing Scientific Value of Clinical Studies

There is a clear sex-gender gap in the prevention and occurrence of diseases, and in the outcomes and treatments, which is relevant to women in the majority of cases. Attitudes concerning the enrollment of women in randomized clinical trials have changed over recent years. Despite this change, a gap still exists. This gap is linked to biological factors (sex) and psycho-social, cultural, and environmental factors (gender). These multidimensional, entangled, and interactive factors may influence the pharmacological response. Despite the fact that regulatory authorities recognize the importance of sex and gender, there is a paucity of research focusing on the racial/ethnic, socio-economic, psycho-social, and environmental factors that perpetuate disparities. Research and clinical practice must incorporate all of these factors to arrive at an intersectional and system-scenario perspective. We advocate for scientifically rigorous evaluations of the interplay between sex and gender as key factors in performing clinical trials, which are more adherent to real-life. This review proposes a set of 12 rules to improve clinical research for integrating sex-gender into clinical trials.

Testing the psychometric properties of the Finnish version of the cross-cultural competence instrument of healthcare professionals (CCCHP)

Background

To test the validity of the Finnish version of the Bernhard et al.’s Cross-Cultural Competence instrument of Healthcare Professionals (CCCHP).

Methods

The study sample comprised registered nurses (N = 810) from the Finnish “Competent workforce for the future” -project (COPE). Exploratory factor analyses and structural equation modelling were applied to test structural validity of the CCCHP. Internal consistency of the sub-scales was evaluated using the Cronbach’s alphas. Criterion validity was explored in terms of received education for multicultural work, perceived difficulty of patients, and job satisfaction variables.

Results

The revised version of the instrument including four (motivation/curiosity, attitudes, skills and emotions/empathy) of the five original dimensions provided satisfactory psychometric properties (internal consistency, a good model fit of the data). Of the four remaining competence sub-scales, motivation/curiosity, attitudes and emotions/empathy were associated with the amount of received education for multicultural work, and all with perceived difficulty of patients, and all but attitudes with job satisfaction.

Conclusion

This revised Finnish version of the CCCHP provides a useful tool for studies focusing on the healthcare personnel’s cross-cultural competence in delivering effective and culturally sensitive healthcare services for patients from different cultures.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4105-2) contains supplementary material, which is available to authorized users.

Can a continuous quality improvement program create culturally safe emergency departments for Aboriginal people in Australia? A multiple baseline study

Background

Providing culturally safe health care can contribute to improved health among Aboriginal people. However, little is known about how to make hospitals culturally safe for Aboriginal people. This study assessed the impact of an emergency department (ED)-based continuous quality improvement program on: the accuracy of recording of Aboriginal status in ED information systems; incomplete ED visits among Aboriginal patients; and the cultural appropriateness of ED systems and environments.

Methods

Between 2012 and 2014, the Aboriginal Identification in Hospitals Quality Improvement Program (AIHQIP) was implemented in eight EDs in NSW, Australia. A multiple baseline design and analysis of linked administrative data were used to assess program impact on the proportion of Aboriginal patients correctly identified as Aboriginal in ED information systems and incomplete ED visits in Aboriginal patients. Key informant interviews and document review were used to explore organisational changes.

Results

In all EDs combined, the AIHQIP was not associated with a reduction in incomplete ED visits in Aboriginal people, nor did it influence the proportion of ED visits made by Aboriginal people that had an accurate recording of Aboriginal status. However, in two EDs it was associated with an increase in the trend of accurate recording of Aboriginality from baseline to the intervention period (odds ratio (OR) 1.31, p < 0.001 in ED 4 and OR 1.15, p = 0.020 in ED 5). In other words, the accuracy of recording of Aboriginality increased from 61.4 to 70% in ED 4 and from 72.6 to 73.9% in ED 5. If the program were not implemented, only a marginal increase would have occurred in ED 4 (from 61.4 to 64%) and, in ED 5, the accuracy of reporting would have decreased (from 72.6 to 71.1%). Organisational changes were achieved across EDs, including modifications to waiting areas and improved processes for identifying Aboriginal patients and managing incomplete visits.

Conclusions

The AIHQIP did not have an overall effect on the accuracy of recording of Aboriginal status or on levels of incomplete ED visits in Aboriginal patients. However, important organisational changes were achieved. Further research investigating the effectiveness of interventions to improve Aboriginal cultural safety is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4049-6) contains supplementary material, which is available to authorized users.

Supporting aboriginal and Torres Strait islander cultural educators and cultural mentors in Australian general practice education

BACKGROUND

Promoting cultural competence of health professionals working with Aboriginal and Torres Strait Islander communities is key to improving health outcomes. Cultural Educators and Cultural Mentors (CE/ CMs) have critical roles in Australian general practice training, yet these are not well understood.

METHODS

Guided by a CE/CM Network, our research team including experienced CE/CMs, used surveys and semi-structured interviews to explore these roles and investigate best practice in employment and support. Participants sampled from stakeholders involved in general practice education across Australia included CE/CMs, Medical Educators, General Practice Supervisors and Registrars, and representatives of Regional Training Organisations, Indigenous Health Training Posts and other key organisations. We undertook thematic analysis using a framework approach, refined further in team discussions that privileged views of CE/ CM members.

RESULTS

Participants comprised 95 interviewees and 55 survey respondents. We organised our findings under three overarching themes: understandings about cultural education and mentoring; employment and support of CE/CMs; and delivery and evaluation of cultural education and mentoring. Our findings supported a central role for Aboriginal and Torres Strait Islander CE/CMs in face-to-face Registrar education about culture and history and related impacts on health and healthcare. Cultural education was reported to provide base-line learning as preparation for clinical practice whilst cultural mentoring was seen as longitudinal, relationship-based learning. Mentoring was particularly valued by Registrars working in Aboriginal and Torres Strait Islander communities. Challenges described with employment and support included difficulties in finding people with skills and authority to undertake this demanding work. Remuneration was problematic, particularly for CMs whose work-time is difficult to quantify, and who are often employed in other roles and sometimes not paid. Other improved support recommended included appropriate employment terms and conditions, flexibility in role definitions, and professional development. Recommendations concerning implementation and evaluation included valuing of cultural education, greater provision of mentoring, partnerships with Medical Educators, and engagement of CE/CMs in rigorous evaluation and assessment processes.

CONCLUSIONS

Our research highlights the importance of the unique CE/CM roles and describes challenges in sustaining them. Professional and organisational support is needed to ensure delivery of respectful and effective cultural education within general practitioner training.

Health workforce cultural competency interventions: a systematic scoping review

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Sharing Histories-a transformative learning/teaching method to empower community health workers to support health behavior change of mothers

BACKGROUND

One of the keys to improving health globally is promoting mothers' adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. Customarily, mothers are taught health messages which, even if simplified, are hard to remember. The challenge is how to promote learning and behavior change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong.

METHODS

In addressing that challenge, a new learning/teaching method called "Sharing Histories" is in development to improve the performance of female community health workers (CHWs) in promoting mothers' behaviors for maternal, neonatal and child health (MNCH).

RESULTS

This method builds self-confidence and empowerment of CHWs in learning sessions that are built on guided sharing of their own memories of childbearing and child care. CHWs can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing CHW programs.

CONCLUSIONS

I present here the Sharing Histories method, describe how it differs from other social and behavior change methods, and discuss selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower CHWs to be more effective change agents with other mothers in their communities, thereby contributing to the attainment of the Sustainable Development Goals.