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

Sociodemographic Predictors of Missed Appointments Among Patients With Cleft Lip and Palate

Objective:

To identify disparities in compliance of and care for patients with cleft lip and/or palate (CL/P) by determining the impact of sociodemographic variables on the rate of missed appointments and Child Protective Services (CPS) involvement.

Design:

A retrospective, noninterventional quality assessment and quality improvement study were designed.

Setting:

This institutional study was performed at the University of Michigan in Ann Arbor, Michigan.

Patients:

All patients born between January 1, 2011, and December 31, 2014, who underwent surgical CL/P repair, excluding those with fewer than 5 appointments (n = 178).

Main Outcome Measure:

The rate of missed appointments, calculated as the total number of no-show appointments divided by the total number of scheduled appointments. All appointments from CL/P diagnosis to data collection were considered, including those outside of plastic surgery.

Results:

The average patient was 4.5 years of age and had 49 total scheduled appointments. The overall rate of missed appointments was 9.6%, with 66.8% of patients missing at least 1 scheduled visit. Patients who were black ( P = .04), not affiliated with a religion ( P = .01), Medicaid users ( P = .01), from an unstable social background ( P = .01), or received need-based financial assistance ( P = .00) were significantly more likely to miss appointments. Child Protective Services was involved with 3.9% of patients.

Conclusions:

Disparities exist in attendance rates among patients with CL/P, and at-risk patient populations have been identified. The allocation of cleft care resources must be efficiently planned in order to enhance the quality of care for at-risk individuals.

Implementation and Evaluation of a Recurring Interdisciplinary Community Health Fair in a Remote U.S.-Mexico Border Community

The purpose of this project was to design, implement, and assess a recurring interdisciplinary community health fair in an underserved border town. University of California San Diego (UCSD) medical and pharmacy students, under faculty supervision, worked alongside community partners in Calexico, California to implement a health fair two miles from the U.S.-Mexico border. Demographic and screening data were described from 293 participants from 2014 to 2016. Over 90% (269/293) listed Mexico as their country of birth, 82.9% (243/293) were monolingual Spanish speakers, 75.4% (221/293) had an annual household income of ≤ $20,000, and 58.7% (172/293) described their health as fair or poor. Screening revealed 91.1% (265/291) were overweight or obese, 37.8% (109/288) had hypertension, 9.3% (27/289) had elevated blood sugar, and 11.4% (33/289) had elevated total cholesterol levels. This model could be replicated in other training settings to increase exposure to border health issues and connect patients to local health services.

Vulnerability in the clinic: case study of a transcultural consultation

Discrimination and inequalities in healthcare can be experienced by many patients due to many characteristics ranging from the obviously visible to the more subtly noticeable, such as race and ethnicity, legal status, social class, linguistic fluency, health literacy, age, gender and weight. Discrimination can take a number of forms including overt racist statement, stereotyping or explicit and implicit attitudes and biases. This paper presents the case study of a complex transcultural clinical encounter between the mother of a young infant in a highly vulnerable social situation and a hospital healthcare team. In this clinical setting, both parties experienced difficulties, generating explicit and implicit negative attitudes that heightened into reciprocal mistrust, conflict and distress. The different factors influencing their conscious and unconscious biases will be analysed and discussed to offer understanding of the complicated nature of human interactions when faced with vulnerability in clinical practice. This case vignette also illustrates how, even in institutions with long-standing experience and many internal resources to address diversity and vulnerability, cultural competence remains a constant challenge.

Oregon's Emphasis On Equity Shows Signs Of Early Success For Black And American Indian Medicaid Enrollees

In 2012 Oregon transformed its Medicaid program, providing coverage through sixteen coordinated care organizations (CCOs). The state identified the elimination of health disparities as a priority for the CCOs, implementing a multipronged approach that included strategic planning, community health workers, and Regional Health Equity Coalitions. We used claims-based measures of utilization, access, and quality to assess baseline disparities and test for changes over time. Prior to the CCO intervention there were significant white-black and white-American Indian/Alaska Native disparities in utilization measures and white-black disparities in quality measures. The CCOs' transformation and implementation of health equity policies was associated with reductions in disparities in primary care visits and white-black differences in access to care, but no change in emergency department use, with higher visit rates persisting among black and American Indian/Alaska Native enrollees, compared to whites. States that encourage payers and systems to prioritize health equity could reduce racial and ethnic disparities for some measures in their Medicaid populations.

Searching for Silver Linings: Is Perceived Medical Discrimination Weaker in Segregated Areas?

An ongoing obstacle in dealing with minority health disparities is discriminatory behavior from healthcare practitioners, also known as medical discrimination. It is not clear, however, if the effects of medical discriminations onto health are constant across space. For example, there is evidence to suspect minorities in racially segregated neighborhoods suffer less from discrimination compared to those living elsewhere. To determine the presence of spatial heterogeneity underlying medical discrimination, we implement logistic geographically weighted regression (GWR) using individual data in the city of Philadelphia from the 2006 and 2008 Public Health Management Corporation's Southeastern Pennsylvania Household Health Surveys. Evaluating the potential role residential segregation has in offsetting medical discrimination, we compare the GWR results to tract data from the 2005-2009 American Community Survey. Through this comparison, we find that the effects of medical discrimination on self-rated health are weaker in magnitude in areas that are mostly minority. However, evidence of direct health benefits for minorities in segregated communities is inconclusive. Thus, while we cannot say living in segregated neighborhoods leads to better minority health, the sting of medical discrimination can be weaker in these places. These results emphasize the importance of local variation, even within a city like Philadelphia, challenging the aspatial one-model-fits-all approach normally found in population studies.

Response to culturally competent drug treatment among homeless persons with different living arrangements

This study investigated the association between program cultural competence and homeless individuals' drug use after treatment in Los Angeles County, California. Los Angeles County has the largest and most diverse population of homeless individuals in the nation. We randomly selected for analysis 52 drug-treatment programs and 2158 participants who identified as homeless in the Los Angeles County Participant Reporting System in 2011. We included their living arrangements (indoors and stable, indoors and unstable, and outdoors) and individual and program characteristics (particularly whether their programs used six culturally competent practices) in multilevel regression analyses. The outcome was days of primary drug use at discharge.Results showed that higher levels of staff personal involvement in minority communities (IRR=0.437; 95% CI=0.222, 0.861) and outreach to minority communities (IRR = 0.406; 95% CI=0.213, 0.771) were associated with fewer days of drug use at discharge. Homeless individuals living outdoors used their primary drug more often than any other group. Yet, compared to individuals with other living arrangements, when outdoor homeless individuals were treated by programs with the highest community resources and linkages (IRR=0.364; 95% CI=0.157, 0.844), they reported the fewest days of drug use. We discuss implications for program evaluation and community engagement policies and practices.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

Factors affecting the cultural competence of visiting nurses for rural multicultural family support in South Korea

Background

With the recent growth of multicultural families in the Korean society, the importance of the role of qualified visiting nurses in the delivery of culturally sensitive health care has grown dramatically. As the primary health care provider for multicultural families enrolled in public community-based health care centers, the cultural competence of visiting nurses is an essential qualification for the provision of quality health care for multicultural families, especially in rural areas. Cultural competence of visiting nurses is based on their cultural awareness and empathetic attitude toward multicultural families. This study aimed to examine the levels of cultural competence, empowerment, and empathy in visiting nurses, and to verify the factors that affect the cultural competence of visiting nurses working with rural multicultural families in South Korea.

Methods

Employing a cross-sectional descriptive study design, data from 143 visiting nurses working in rural areas were obtained. Data collection took place between November 2011 and August 2012. The measurement tools included the modified Korean version of the Cultural Awareness Scale, the Text of Items Measuring Empowerment, and the Interpersonal Reactivity Index to measure the level of empathy of visiting nurses. Analyses included descriptive statistics, a t-test, an ANOVA, a Pearson correlation coefficient analysis, and a multiple linear regression analysis.

Results

The cultural competence score of the visiting nurses was 3.07 on a 5-point Likert scale (SD = 0.30). The multiple regression analysis revealed that the cultural competence of visiting nurses was significantly influenced by experience of cultural education, empathy, and scores on the meaning subscale of the empowerment tool (R² = 10.2%).

Conclusions

Institutional support to enhance visiting nurses' empowerment by assuring the significance of their job and specific strategies to enhance their empathy would be helpful to improve the cultural competence of visiting nurses. Additionally, regular systematic education on culturally sensitive care would be helpful to enable visiting nurses to provide culturally sensitive care for multicultural families.

Examining the online approaches used by hospitals in Sydney, Australia to inform patients about healthcare associated infections and infection prevention strategies

Background

Provision of information plays a critical role in supporting patients to be engaged or empowered to be involved with infection prevention measures in hospitals. This explorative study evaluated the suitability, readability and accessibility of information on healthcare associated infections (HCAIs) and infection prevention strategies targeted at patients from the websites of 19 acute care public hospitals in Sydney, Australia.

Methods

We included hospitals with greater than 200 beds in the sample. We examined online information targeted at patients on HCAIs and infection prevention and compared it using the Suitability Assessment of Material (SAM) and Simple Measure of Gobbledygook (SMOG) readability formulas for suitability, readability and accessibility.

Results

Thirty-six webpages were identified as being relevant and containing information about HCAIs or infection prevention. Based on the SAM/SMOG scores, only three webpages were found to be ‘superior’. Many of the webpages scored poorly in content, literacy, graphics, learning stimulation and cultural appropriateness. In comparison, most of the webpages scored well in the layout and typography. The majority (97%) of the materials were written at a level higher than the recommended reading grade level. Lastly, the websites scored poorly on the ability to locate the information easily, as messages about HCAIs/infection prevention were usually embedded into other topics.

Conclusion

While providing information online is only one approach to delivering messages about infection prevention, it is becoming increasingly important in today’s technology society. Hospitals are neglecting to use best practices when designing their online resources and current websites are difficult to navigate. The findings point to the need to review patient information on HCAIs regarding suitability, readability and accessibility.

Advancing theory development: exploring the leadership-climate relationship as a mechanism of the implementation of cultural competence

BACKGROUND

Leadership style and specific organizational climates have emerged as critical mechanisms to implement targeted practices in organizations. Drawing from relevant theories, we propose that climate for implementation of cultural competence reflects how transformational leadership may enhance the organizational implementation of culturally responsive practices in health care organizations.

METHODS

Using multilevel data from 427 employees embedded in 112 addiction treatment programs collected in 2013, confirmatory factor analysis showed adequate fit statistics for our measure of climate for implementation of cultural competence (Cronbach's alpha = .88) and three outcomes: knowledge (Cronbach's alpha = .88), services (Cronbach's alpha = .86), and personnel (Cronbach's alpha = .86) practices.

RESULTS

Results from multilevel path analyses indicate a positive relationship between employee perceptions of transformational leadership and climate for implementation of cultural competence (standardized indirect effect = .057, bootstrap p < .001). We also found a positive indirect effect between transformational leadership and each of the culturally competent practices: knowledge (standardized indirect effect = .006, bootstrap p = .004), services (standardized indirect effect = .019, bootstrap p < .001), and personnel (standardized indirect effect = .014, bootstrap p = .005).

CONCLUSIONS

Findings contribute to implementation science. They build on leadership theory and offer evidence of the mediating role of climate in the implementation of cultural competence in addiction health service organizations.

Increasing Community Research Capacity to Address Health Disparities

The Community Research Fellows Training program is designed to enhance capacity for community-based participatory research; program participants completed a 15-week, Master of Public Health curriculum. We conducted qualitative, semistructured interviews with 81 participants from two cohorts to evaluate the learning environment and how the program improved participants' knowledge of public health research. Key areas that provided a conducive learning environment included the once-a-week schedule, faculty and participant diversity, and community-focused homework assignments. Participants discussed how the program enhanced their understanding of the research process and raised awareness of public health-related issues for application in their personal lives, professional occupations, and in their communities. These findings highlight key programmatic elements of a successful public health training program for community residents.

Cultural competency and communication skills of dental students: clinical supervisors' perceptions

OBJECTIVES

This study explored clinical supervisor's (CS) views and experiences of dental students' cultural competence (CC) at the Melbourne Dental School, The University of Melbourne, Australia. Additionally, this study explored CS insights into how CC could be taught.

METHODS

Semi-structured one-to-one interviews were organised with consenting CS. Interview topics included the following: the importance of CC, communication and rapport, the role of culture in oral health and the need for curriculum enhancement. Interviews were recorded, transcribed and thematically analysed to identify key areas using NVivo software.

RESULTS

A total of 12 CS participated in this study. CS acknowledged the importance of CC and felt that it was important for good patient management. CS's definition of CC focused primarily on language and communication skills. CS felt that dental students were generally able to manage culturally diverse patients. However, CS indicated that additional training in this area would be beneficial. Concerns were raised about the students' ability to establish good rapport and communication, with CS highlighting areas such as misuse of interpreters and use of jargon. CS felt that clinical experience, confidence and a positive attitude are effective tools for overcoming cultural barriers. Furthermore, some CS also felt that cultural competency was a skill that is learnt through experience.

CONCLUSIONS

For most CS, cultural competence was an important part of the clinician-patient exchange which would benefit from enhanced curriculum. They also highlighted areas where transcultural education could be improved. The majority of CS believed dental students managed culturally diverse patients well.

Indigenous health: designing a clinical orientation program valued by learners

BACKGROUND

Indigenous health programs are seen as a curriculum response to addressing health disparities and social accountability. Several interrelated teaching approaches to cultural competency curricula have been recommended, however evidence of the impact of these on learner outcomes including engagement and self-reported competencies is limited. We aimed to explore undergraduate medical student perspectives of an indigenous health orientation program to inform curriculum strategies that promote learning and development of clinical skills.

METHODS

We analyzed quantitative and qualitative student evaluations (n = 602) of a three-day immersed indigenous health orientation program between 2006 and 2014 based on Likert-scale responses and open-text comments. We conducted a thematic analysis of narrative student experiences (n = 426).

RESULTS

Overall, 509 of 551 respondents (92%) rated the indigenous health orientation program as extremely or highly valuable and most (87%) reported that the course strongly increased their interest in indigenous health. The features of the clinical course that enhanced value for learners included situated learning (learning environment; learning context); teaching qualities (enthusiasm and passion for Māori health; role-modelling); curriculum content (re-presenting Māori history; exploring Māori beliefs, values and practices; using a Māori health framework in clinical practice); teaching methodologies (multiple teaching methods; simulated patient interview); and building relationships with peers (getting to know the student cohort; developing professional working relationships).

CONCLUSIONS

Undergraduate medical students valued an indigenous health program delivered in an authentic indigenous environment and that explicitly reframed historical notions of indigenous health to contextualize learning. Content relevant to clinical practice, faculty knowledge, and strengthened peer interactions combined to build learner confidence and self-reported indigenous health competencies. These findings suggest empirical evidence to support a curriculum approach to indigenous health teaching that enhances clinical learning.

Does the implementation of evidence-based and culturally competent practices reduce disparities in addiction treatment outcomes?

RATIONALE

Research is limited on the extent to which implementation of evidence-based and culturally responsive practices reduces outcome disparities in substance use disorder treatment. We examined the role of contingency management treatment (CMT), medication-assisted treatment (MAT), and culturally competent practices on Mexican Americans' rate of successful completion of treatment.

METHODS

We analyzed a concatenated dataset from 153 publicly funded substance use disorder treatment programs in Los Angeles County, California, in 2011 and 2013. These data were merged with data from 15,412 adult clients in both periods, of whom we selected only Mexican Americans (46.3%) and non-Latino Whites (53.7%). The outcome was successful treatment completion. The main independent variables were client demographics, drug use severity, mental health issues, and program license and professional accreditation.

RESULTS

Less than half of the programs highly implemented CMT, MAT, and culturally competent practices. CMT and cultural competence were not associated with successful treatment completion. However, Mexican Americans in programs with high degree of implementation of MAT had higher odds of successfully completing treatment compared to non-Latino Whites and programs with low MAT (OR=1.389; 95% CI=1.018, 1.897).

CONCLUSIONS

Findings highlight the role of MAT in reducing the disparity in treatment completion between Mexican Americans and non-Latino Whites. Implications for health policy and the dissemination of MAT are discussed.

Cultural barriers in access to healthcare services for people with disability in Iran: A qualitative study

Background: People with disability experience various problems to access to healthcare services. This study aimed to identify cultural barriers in access to healthcare services for people with disability in Iran.

Methods: We conducted a qualitative study using content analysis to identify the cultural barriers. We used semi-structured interviews to collect data. Participants were selected through purposeful sampling with maximum variation. 50 individual interviews were conducted with three groups of people with disability, healthcare services providers and policy makers, September to May 2015, at different locations in Tehran, Iran.

Results: We identified a number of different cultural barriers in access to health services for people with disability in Iran. These related to health service providers, namely reluctance to provide health services and disrespect; related to People with disability, namely denial of disability, disproportionate expectation, shame and insufficient sociocultural supports; and related to policy makers, namely lack of concern, little attention to the culture of disability and discrimination. We categorized misconception as a barrier that was observed at all levels of the society.

Conclusion: Disability is a reality that some human being may experience and live with it. The negative attitude towards people with disability has a close relationship with the cultural norms of a society. The culture of disability in different dimensions should be a priority for all policy makers. Removing cultural barriers in access to healthcare for people with a disability needs collective efforts and collaborations among all stakeholders.

Primary Care for Underserved Populations: Navigating Policy to Incorporate Occupational Therapy Into Federally Qualified Health Centers

Federally qualified health centers (FQHCs) provide low- or no-cost primary care to medically underserved populations such as homeless or low-income people, migrant workers, and members of marginalized cultural groups. Occupational therapy services have the potential to help improve the health and functioning of FQHC patients. Using a FQHC serving American Indian/Alaska Native populations as a case example, we describe how occupational therapy is well suited to help meet the needs of medically underserved populations. We then examine options for integrating occupational therapy into this unique primary care setting, discuss related administrative and policy considerations, and propose possible solutions to identified barriers.

Improving access to mental health care in an Orthodox Jewish community: a critical reflection upon the accommodation of otherness

Background

The English National Health Service (NHS) has significantly extended the supply of evidence based psychological interventions in primary care for people experiencing common mental health problems. Yet despite the extra resources, the accessibility of services for ‘under-served’ ethnic and religious minority groups, is considerably short of the levels of access that may be necessary to offset the health inequalities created by their different exposure to services, resulting in negative health outcomes. This paper offers a critical reflection upon an initiative that sought to improve access to an NHS funded primary care mental health service to one ‘under-served’ population, an Orthodox Jewish community in the North West of England.

Methods

A combination of qualitative and quantitative data were drawn upon including naturally occurring data, observational notes, e-mail correspondence, routinely collected demographic data and clinical outcomes measures, as well as written feedback and recorded discussions with 12 key informants.

Results

Improvements in access to mental health care for some people from the Orthodox Jewish community were achieved through the collaborative efforts of a distributed leadership team. The members of this leadership team were a self-selecting group of stakeholders which had a combination of local knowledge, cultural understanding, power to negotiate on behalf of their respective constituencies and expertise in mental health care. Through a process of dialogic engagement the team was able to work with the community to develop a bespoke service that accommodated its wish to maintain a distinct sense of cultural otherness.

Conclusions

This critical reflection illustrates how dialogic engagement can further the mechanisms of candidacy, concordance and recursivity that are associated with improvements in access to care in under-served sections of the population, whilst simultaneously recognising the limits of constructive dialogue. Dialogue can change the dynamic of community engagement. However, the full alignment of the goals of differing constituencies may not always be possible, due the complex interaction between the multiple positions and understandings of stakeholders that are involved and the need to respect the other’-s’ autonomy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2509-4) contains supplementary material, which is available to authorized users.

The association between car accident fatalities and children's fears: A study in seven EU countries

Children's fear of a car accident occurring to parents or themselves has been used as a concrete example to illustrate one of the symptoms of anxiety disorders such as separation anxiety and generalized anxiety. However, its usage across countries may be questionable where the prevalence of this specific type of injury differs. This cross-sectional study compares samples from seven diverse European countries (Bulgaria, Germany, Italy, Lithuania, Netherlands, Romania, Turkey) to see if an environmental exposure, car accident death rate per 100,000 people (country-wide from WHO data), is associated with children's self-report of car accident fears. In this study, 6-11 year-old children were surveyed by a diagnostic instrument (Dominic Interactive) about several situations and asked if they believed they were similar to a fictional child depicted in said situations. Mothers were surveyed for additional sociodemographic information. Multivariable logistic regression was used to adjust for covariates including mother's age, mother's education, single parenting, and mother's professional inactivity. We report a monotonic relationship between higher car accident death rates and the prevalence of children reporting fear of parent's or own accident. Relative to a reference of 3.9 deaths per 100,000 people, children's odds of reporting fear of parent's accident ranged from 1.99 (95% CI 1.51-2.61) times to 4.84 (95% CI 3.68-6.37) times as the risk of death by car accident increased across countries. A similar result arose from fear of child's own accident, with significant ORs ranging from 1.91 (95% CI 1.53-2.40) to 2.68 (95% CI 2.07-3.47) alongside increased death rates. Given that reporting of these fears accompanies correspondingly high accident death rates, the pertinence of using fear of car accidents as an illustration for some diagnostic item for mental disorders cross-nationally appears to be an issue.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION AND IMPLICATIONS

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

The impact of personalisation on people from Chinese backgrounds: qualitative accounts of social care experience

The limited research that considers people from black and minority ethnic communities' experiences of personalisation tends to focus on personal budgets rather than personalisation per se. This article provides an opportunity to hear the voices of people from Chinese backgrounds and their experiences of personalisation. The study used individual semi-structured interviews and focus groups to collect data from physically disabled people from Chinese backgrounds who lived in England, were aged between 18 and 70, and received social care. Data were analysed using an iterative and thematic approach, with early analysis informing the subsequent analytical rounds. The findings reveal that personalisation has the potential to transform the lives of people from Chinese backgrounds, especially when tailored support is available for people to understand and access personal budgets and put them to creative use. However, the impact of personalisation is barely evident because few eligible individuals access personal budgets or participate in co-production. This is related to a lack of encouragement for service users to become genuine partners in understanding, designing, commissioning and accessing a diverse range of social care services to meet their cultural and social care needs.

Taiwanese medical students' narratives of intercultural professionalism dilemmas: exploring tensions between Western medicine and Taiwanese culture

In an era of globalization, cultural competence is necessary for the provision of quality healthcare. Although this topic has been well explored in non-Western cultures within Western contexts, the authors explore how Taiwanese medical students trained in Western medicine address intercultural professionalism dilemmas related to tensions between Western medicine and Taiwanese culture. A narrative interview method was employed with 64 Taiwanese medical students to collect narratives of professionalism dilemmas. Noting the prominence of culture in students' narratives, we explored this theme further using secondary analysis, identifying tensions between Western medicine and Taiwanese culture and categorizing students' intercultural professionalism dilemmas according to Friedman and Berthoin Antal's 'intercultural competence' framework: involving combinations of advocacy (i.e., championing one's own culture) and inquiry (i.e., exploring one's own and others' cultures). One or more intercultural dilemmas were identified in nearly half of students' professionalism dilemma narratives. Qualitative themes included: family relations, local policy, end-of-life care, traditional medicine, gender relations and Taiwanese language. Of the 62 narratives with sufficient detail for further analysis, the majority demonstrated the 'suboptimal' low advocacy/low inquiry approach (i.e., withdrawal or inaction), while very few demonstrated the 'ideal' high advocacy/high inquiry approach (i.e., generating mutual understanding, so 'intercultural competence'). Though nearly half of students' professionalism narratives concerned intercultural dilemmas, most narratives represented disengagement from intercultural dilemmas, highlighting a possible need for more attention on intercultural competence training in Taiwan. The advocacy/inquiry framework may help educators to address similar disconnects between Western medicine and non-Western cultures in other contexts.

Reimagining Cultural Competence: Bringing Buried Dynamics Into the Light

Many organizations attempt to increase cultural competence as one way to foster organizational change to enhance equity and inclusion. But the literature on cultural competence is largely silent on the role of emotion, despite the strong feelings that inevitably accompany work in cross-racial dyads, groups, and institutions. We offer group relations theory as an approach rooted in the importance of emotions, especially anxiety, and offering a rich awareness of how unconscious processes, including defense mechanisms like splitting and projection, drive that anxiety. We show how this approach helps us both diagnose and address difficult dynamics, including by recognizing entrenched power inequities. We draw on examples from others’ research as well as our own research, teaching, and consulting to illustrate key concepts. Ultimately, we argue that buried emotions can create distance and inhibit change. Surfacing and addressing them can foster connection and provide a way for organizations to move forward.

Culturally competent library services and related factors among health sciences librarians: an exploratory study

Objective

This study investigated the current state of health sciences libraries’ provision of culturally competent services to support health professions education and patient care and examined factors associated with cultural competency in relation to library services and professional development.

Methods

This was a cross-sectional study. Data were collected with a survey questionnaire that was distributed via SurveyMonkey to several health sciences librarian email discussion lists.

Results

Out of 176 respondents, 163 reported serving clients from diverse cultural backgrounds. Various services were provided to develop or support initiatives in cultural competency in health professions education and patient care. A considerable number of respondents were unsure or reported no library services to support initiatives in cultural competency, although a majority of respondents perceived the importance of providing culturally competent library services (156, 89.1%) and cultural competency for health sciences librarians (162, 93.1%). Those who self-identified as nonwhites perceived culturally competent services to be more important than whites (p=0.04). Those who spoke another language in addition to English had higher self-rated cultural competency (p=0.01) than those who only spoke English.

Conclusions

These findings contribute to our knowledge of the types of library services provided to support cultural competency initiatives and of health sciences librarians’ perceived importance in providing culturally competent library services and cultural competency for health sciences librarians. The results suggest implications for health sciences libraries in fostering professional development in cultural competency and in providing culturally competent services to increase library use by people from a wide range of cultures and backgrounds.

Towards culturally competent paediatric oncology care. A qualitative study from the perspective of care providers

In order to gain more insight on the influence of ethnic diversity in paediatric cancer care, the perspectives of care providers were explored. Semi-structured interviews were conducted among 12 paediatric oncologists and 13 nurses of two different paediatric oncology wards and were analysed using a framework method. We found that care providers described the contact with Turkish and Moroccan parents as more difficult. They offered two reasons for this: (1) language barriers between care provider and parents hindered the exchange of information; (2) cultural barriers between care provider and parents about sharing the diagnosis and palliative perspective hindered communication. Care providers reported different solutions to deal with these barriers, such as using an interpreter and improving their cultural knowledge about their patients. They, however, were not using interpreters sufficiently and were unaware of the importance of eliciting parents' perspectives. Communication techniques to overcome dilemmas between parents and care providers were not used and care providers were unaware of stereotypes and prejudice. Care providers should be offered insight in cultural barriers they are unaware of. Training in cultural competence might be a possibility to overcome manifest barriers.

Caring by Numbers: Evaluation of Inconsistencies and Incompleteness in the Reporting of Racial and Ethnic Data

Significant health disparities throughout the lifespan have long been evident within the American, non-White population. These differences include increased incidence of infant mortality, childhood hospitalization, diabetes, mental and behavioral health problems, cardiovascular disease, and late-stage cancer diagnoses. These types of disparities could be addressed by identifying those individuals at greatest risk for chronic disease or higher mortality rates and improving their health literacy and access to care. However, this is only possible if health management organizations and care providers have accurate racial and ethnic information. As an initial step at better understanding the problem, a survey of demographic data for Ohio Medicaid beneficiaries was conducted. The results of the study revealed inconsistencies and omissions in reported race and ethnicity for nearly 10% of records received from the state. This trend was most evident among older adults and those joining under the Affordable Care Act's Medicaid Expansion. Collectively, these results suggest that the first step in correcting health disparities may be to ensure that accurate information is available about the target population.

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

BACKGROUND

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

METHODS

This scoping review was completed as part of a larger systematic literature search conducted on evaluations of cultural competence interventions in health care in Canada, the United States, Australia, and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched. Overall, 64 studies on cultural competency interventions were found, with 22 being health promotion programs and services. A process of thematic analysis was utilized to identify key intervention strategies and outcomes reported in the literature.

RESULTS

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

DISCUSSION

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

Nurse-Environment Interactions in the Development of Cultural Competence

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

Cross-Cultural Care Training for Pediatric Hematology/Oncology Fellows

INTRODUCTION

Physicians are entrusted with the medical care of culturally and socially diverse patient populations. In addition, pediatric hematologists/oncologists are faced with the challenge of taking care of children with life-threatening and complex conditions. We implemented a cross-cultural care training curriculum for our pediatric hematology/oncology fellows with the goal of preparing them to handle complex clinical situations while navigating different social and cultural belief systems.

METHODS

The curriculum includes a precourse self-reflection; a learning module with a review of published literature; faculty-facilitated small-group role-play simulations; interactive sessions with language interpreters and physicians from different cultural, ethnic, and religious belief systems; and a postcourse reflection.

RESULTS

Fellows who participated in the curriculum strongly agreed that the module was helpful, indicating that it enhanced their communication skills, improved delivery of cross-cultural care, and had a sustained impact on their interaction with medical language interpreters.

DISCUSSION

Cross-cultural care training should be integrated into any pediatric hematology/oncology training curriculum. Sessions directed at addressing the perceived gaps between physician awareness and the patient's belief systems can increase awareness of personal biases in practice and improve interview techniques. Likewise, self-reflection can help physicians apply their medical knowledge and skills in the appropriate cultural and social context, thereby improving patient satisfaction, partnerships, and health care outcomes.

Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care

BACKGROUND

Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services.

METHODS

Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data.

RESULTS

Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals.

CONCLUSION

Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care.

Residents' Attitude, Knowledge, and Perceived Preparedness Toward Caring for Patients from Diverse Sociocultural Backgrounds

Purpose: Training residents to deliver care to increasingly diverse patients in the United States is an important strategy to help alleviate racial and ethnic disparities in health outcomes. Cross-cultural care training of residents continues to present challenges. This study sought to explore the associations among residents' cross-cultural attitudes, preparedness, and knowledge about disparities to better elucidate possible training needs. Methods: This cross-sectional study used web-based questionnaires from 2013 to 2014. Eighty-four internal medicine residency programs with 954 residents across the United States participated. The main outcome was perceived preparedness to care for sociocultural diverse patients. Key Results: Regression analysis showed attitude toward cross-cultural care (beta coefficient [β]=0.57, 95% confidence interval [CI]: 0.49-0.64, p<0.001) and report of serving a large number of racial/ethnic minorities (β=0.90, 95% CI: 0.56-1.24, p<0.001), and low-socioeconomic status patients (β=0.74, 95% CI: 0.37-1.10, p<0.001) were positively associated with preparedness. Knowledge of disparities was poor and did not differ significantly across postgraduate year (PGY)-1, PGY-2, and PGY-3 residents (mean scores: 56%, 58%, and 55%, respectively; p=0.08). Conclusion: Residents' knowledge of health and healthcare disparities is poor and does not improve during training. Residents' preparedness to provide cross-cultural care is directly associated with their attitude toward cross-cultural care and their level of exposure to patients from diverse sociocultural backgrounds. Future studies should examine the role of residents' cross-cultural care-related attitudes on their ability to care for diverse patients.

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

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

Cultural competence in medical education: A questionnaire study of Danish medical teachers' perceptions of and preparedness to teach cultural competence

AIMS

The cultural competence training of healthcare professionals is a key element in ensuring the quality of both the access and delivery of healthcare to increasingly ethnically diverse populations. The aim of this study is to investigate Danish medical teachers' opinions about cultural competence, their willingness to receive training and preparedness to teach cultural competence topics.

METHODS

The survey was sent to medical teachers, clinical teachers and external lecturers who teach in the medical programme at the University of Copenhagen. A total of 1400 medical teachers received the survey, and 199 responded. The response rate is 14%. Data were analysed through descriptive calculations, and answers to open-ended questions were coded using content analysis.

RESULTS

Results showed that 82.4% of the informants agreed or strongly agreed that the medical education programme should include training on cultural issues, and 60.3% agreed or strongly agreed that students should be assessed on their cultural competence skills. Regarding preparedness to teach a diverse classroom, 88.4% felt somewhat or very prepared to engage and motivate all students. About 70% were interested in receiving training on cultural competence.

CONCLUSIONS

Generally, there is interest in and acknowledgement of the importance of cultural competence in Danish medical education among teachers at the University of Copenhagen. This creates an opportunity to implement cultural competence in the medical curriculum, training of teachers and strengthening the diversity sensitivity of the organisation. However, support for this programme by management and the allocation of an appropriate level of resources is a prerequisite to the success of the programme.

Contextualizing Competence: Language and LGBT-Based Competency in Health Care

Changes in the language and terminology used to refer to individuals identifying as lesbian, gay, bisexual, and transgender (LGBT), as well as how best to discuss issues of sexual and gender identity, can prove challenging for health care providers due to (1) lack of training; (2) interdisciplinary issues; and (3) prejudices on personal and institutional levels. Given the importance of language in the relationship between health care provider and patient as well as the myriad ways in which language can reflect knowledge, skills, and attitudes, we contend that language is both a facilitator and inhibitor of competence. In this article, we discuss language as a means of exhibiting cultural competence as well as the barriers to facilitating this degree of competence. Communicative competence, a concept traditionally used in linguistics, is discussed as a framework for contextualizing LGBT-specific cultural competence in health care. Ideally, a professional will be considered competent once they (1) acquire a foundation in issues associated with LGBT individuals, as well as a basic understanding of appropriate vocabulary' (2) reconcile personal beliefs with their professional role; (3) create an inclusive healthcare environment such that the influence of personal biases does not negatively impact care; and (4) use identifiers suggested by the patient.

Cultural challenges to engaging patients in shared decision making

OBJECTIVE

Engaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.

DISCUSSION

The past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.

CONCLUSION

While preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.

Pharmacy students' use of and beliefs about traditional healthcare

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

Does Racial/Ethnic Identity Influence the Effectiveness of a Community Health Worker Intervention for African American and Latino Adults With Type 2 Diabetes?

Background. Community health worker (CHW) interventions are known to be an effective strategy to improve health behaviors and outcomes in relation to diabetes, particularly for racial/ethnic communities. Although understanding the function of identity with same race/ethnicity among clients of CHW interventions could contribute to more effective program design, few studies have explored whether levels of racial/ethnic identity among participants can influence the effectiveness of CHW interventions. Aims. We tested the relationship between level of racial/ethnic identity and changes in hemoglobin A1c and diabetes self-efficacy among low-income African American and Latino adults with type 2 diabetes who participated in a CHW intervention. Methods. Data came from a randomized controlled trial of the CHW intervention with a 6-month delayed control group design for 164 African American and Latino adults in Detroit, Michigan. Racial/ethnic identity was created from two items and classified into high, moderate, and low. We combined the two arms (immediate and delayed) into one because there was no significant difference in baseline characteristics, other than age and postintervention self-efficacy, and multivariable linear regression models were applied in the analysis. Results. Possession of high racial/ethnic identity was associated with greater improvement both in hemoglobin A1c and diabetes self-efficacy at 6 months. Moreover, among those with high hemoglobin A1c at preintervention, higher racial/ethnic identity had a greater impact on hemoglobin A1c improvement, compared with those with lower identity. Conclusions. This study suggests the importance of considering racial/ethnic identity of the participants in designing and operating the CHW intervention for racial/ethnic minority population.

Developing cultural competence in general practitioners: an integrative review of the literature

Background

Cultural competence is a broad concept with multiple theoretical underpinnings and conflicting opinions on how it should be materialized. While it is recognized that cultural competence should be an integral part of General Practice, literature in the context of General Practice is limited.

The aim of this article is to provide a comprehensive summary of the current literature with respect to the following: the elements of cultural competency that need to be fostered and developed in GPs and GP registrars; how is cultural competence being developed in General Practice currently; and who facilitates the development of cultural competence in General Practice.

Methods

We conducted an integrative review comprising a systematic literature search followed by a synthesis of the results using a narrative synthesis technique.

Results

Fifty articles were included in the final analysis. Cultural competence was conceptualized as requiring elements of knowledge, awareness/attitudes and skills/behaviours by most articles. The ways in which elements of cultural competence were developed in General Practice appeared to be highly varied and rigorous evaluation was generally lacking, particularly with respect to improvement in patient outcomes. Formal cultural competence training in General Practice appeared to be underdeveloped despite GP registrars generally desiring more training. The development of most aspects of cultural competence relied on informal learning and in-practice exposure but this required proper guidance and facilitation by supervisors and educators. Levels of critical and cultural self-reflection amongst General Practitioners and GP registrars varied and were potentially underdeveloped. Most standalone training workshops were led by trained medical educators however the value of cultural mentors was recognised by patients, educators and GP registrars across many studies.

Conclusions

Cultural competency development of GP registrars should receive more focus, particularly training in non-conscious bias, anti-racism training and critical self-reflectiveness. There is a need for further exploration of how cultural competence training is delivered within the GP training model, including clarifying the supervisor’s role.

It is hoped this discussion will inform future research and training practices in order to achieve quality and respectful care to patients across cultures, and to remove health inequities that exist between cultural groups.

Pediatric Community Mental Health

The emotional health and wellbeing of children and adolescents and their families is of utmost importance. Pediatricians are at the front line in identifying mental illness in children and adolescents and either linking them to resources in the community or providing treatment options themselves. Collaboration and integrative health care models is the cornerstone of effective strategies to provide access and quality mental health care to children and families in communities across the country.

Cultural Humility and Hospital Safety Culture

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

It's a Matter of Trust: Older African Americans Speak About Their Health Care Encounters

PURPOSE

To examine perceptions of older African Americans' encounters with health care providers and ways to enhance trust.

METHOD

Transcribed semi-structured interviews with African American senior center members were analyzed, using Pattern Coding method.

RESULTS

Four themes emerged: "Added Insult of Ageism," "Alternative Remedies," "Good Providers in a 'Broken' System," and "The Foundation of Trust Is Person Recognition." Provider behaviors leading to mistrust included erroneously assuming stereotypical preferences and competence, spending inadequate time listening to patients, disregarding patient preferences, and insufficiently explaining treatments.

DISCUSSION

Of importance to improving trust among older African American patients is valuing individual histories and preferences by reallocating scarce time to person-centered listening, individualizing treatments, more completely explaining interventions, and assuring that patients understand and agree with treatment plans.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding Hearing Loss and Barriers to Hearing Health Care Among Korean American Older Adults: A Focus Group Study

Hearing loss is associated with an accelerated decline in social, cognitive, and physical functioning among older adults. However, little is known about its impact and barriers to hearing health care in any ethnic minorities. The aim of this study was to explore experiences related to hearing loss and barriers to hearing health care among older Korean Americans (KAs). We conducted four focus groups with 19 older KAs with hearing loss and four communication partners. Qualitative content analysis revealed four themes: (a) impact of hearing loss, (b) self-perception of hearing loss, (c) coping strategies for hearing loss, and (d) barriers to hearing health care (price, language, lack of collaborative communications, perceptions about hearing aids, and lack of knowledge). Older KAs were significantly impacted by hearing loss but tended not to seek care due to multiple factors. Culturally tailored hearing interventions are urgently needed to promote hearing health in the KA community.

Literature Review of the National CLAS Standards: Policy and Practical Implications in Reducing Health Disparities

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care are a practical tool for health and health care organizations to improve their provision of culturally and linguistically appropriate services (CLAS). Published by the Office of Minority Health at the U.S. Department of Health and Human Services, the National CLAS Standards provide health and health care organizations with a set of action steps for better meeting the needs of individuals from culturally and linguistically diverse backgrounds. Few studies have examined the concept of CLAS or the National CLAS Standards, and they have rarely been extensively studied or reviewed. The authors conducted three literature searches between February 2014 and May 2015, examining the organizational challenges, applicability, and policy implications related to the National CLAS Standards or CLAS, and selected 55 articles for inclusion in the review. The literature highlights a number of challenges in implementing the National CLAS Standards and/or providing CLAS, including issues related to the communication within health care organizations and the inconsistency of accountability measures. This literature review contributes to the growing knowledge base of the National CLAS Standards and CLAS in health and health care.