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

University–Community–Hospice Partnership to Address Organizational Barriers to Cultural Competence

Research documents a lack of access to, utilization of, and satisfaction with hospice care for African Americans. Models for culturally competent hospice services have been developed but are not in general use. Major organizational barriers include (1) lack of funding/budgeting for additional staff for community outreach, (2) lack of applications from culturally diverse professionals, (3) lack of funding/budgeting for additional staff for development of culturally competent services, (4) lack of knowledge about diverse cultures, and (5) lack of awareness of which cultural groups are not being served. A participatory action research project addressed these organizational barriers through a multicultural social work student field placement in 1 rural hospice. The effectiveness of the student interventions was evaluated, including addressing organizational barriers, cultural competence training of staff, and community outreach. Results indicated that students can provide a valuable service in addressing organizational barriers through a hospice field placement.

Intimate partner violence and physical health outcomes among Southeast Asian American women

Although intimate partner violence is prevalent among Southeast Asian American women, little is known about the associations between the experience of intimate partner violence and negative health outcomes in this population. Resnick et al. proposed a model explaining the development of health problems following violent assault. This article assesses the applicability of Resnick et al.'s model to Southeast Asian American women who have experienced intimate partner violence by reviewing cultural, historical, and social factors in this population. Our review indicates that the applicability of Resnick et al.'s model to Southeast Asian American women is mixed, with some components of the model fitting well with this population and others requiring a more nuanced and complex perspective. Future studies should take into consideration cultural, historical, and social factors.

Parental Literacy and Infant Health: An Evidence-Based Healthy Start Intervention

Syracuse Healthy Start, a federally funded infant mortality prevention project in Onondaga County, New York, has undertaken a range of interventions to address parental low literacy as a risk factor for infant mortality. A growing number of studies advocate for health-related information that is easy to read, of a low literacy level, and culturally appropriate. Creation of an evidence-based public health intervention involves analyzing local data, reviewing published studies, assessing available materials, initiating programmatic interventions, and evaluating the outcomes. Preparing health educational materials that are clear, culturally sensitive, and at appropriate reading levels follows Paulo Freire’s lead in empowering the disadvantaged to positively affect their health and the health of their infants toward the reduction of infant mortality.

Community Development Model for Public Health Applications: Overview of a Model to Eliminate Population Disparities

For well over two decades, the public health community has undertaken a broad range of initiatives to identify and eliminate various health-related disparities among populations. The Centers for Disease Control and Prevention’s (CDC) Office on Smoking and Health (OSH), for example, has committed resources to help states eliminate population disparities related to tobacco use. These initiatives have enjoyed a degree of success and some measurable decreases in population disparities. However, traditional public health approaches that are overly influenced by reductionist paradigms more content with risk factor assessment of at-risk strata may not be sufficient to produce successful results when applied to more intractable disparities. The elimination of disparities will require a more encompassing and comprehensive approach that addresses both population strata at risk and the communities in which they reside. This article proposes a new, concentrated model to address the elimination of population disparities—a model that focuses on community as the critical unit of analysis and action to achieve success.

Clinician/Patient Connections in Ethnoculturally Nonconcordant Encounters With Political-Asylum Seekers: A Comparison of Physicians and Nurses

The article compares the ability of nurses and physicians to connect with patients in ethnoculturally nonconcordant clinical encounters with 41 randomly selected political-asylum seekers (PAS) residing at five Finnish reception centers in summer 2002. Doctors and nurses were equally unlikely to draw congruent assessments of the patient’s past and present health condition, mixed use of biomedical/ethnocultural practices, adherence with medication and eat/drink instructions, (dis)satisfaction, and future confidence in recommended biomedical and ethnocultural approaches. Nurses were considerably more likely to hold views that were congruent with the patient’s reported health care effectiveness in Finland. The findings suggest that doctors should request and place special weight on the insights of the principal attending nurse when assessing the potential contributions of personal, family, and host-society health care assets and inhibitors to a migrant patient’s overall health plan. The results also suggest that culturally sensitive health care training offers specific advantages to nurses who attend to PAS.

A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients

Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dual-minority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender ("LGBT") racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.

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

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

The Pain Experience of Hispanic Americans: A Critical Literature Review and Conceptual Model

Although the Hispanic population is a burgeoning ethnic group in the United States, little is known about their pain-related experience. To address this gap, we critically reviewed the existing literature on pain experience and management among Hispanic Americans (HAs). We focused our review on the literature on nonmalignant pain, pain behaviors, and pain treatment seeking among HAs. Pain management experiences were examined from HA patients' and health care providers' perspectives. Our literature search included variations of the term "Hispanic" with "AND pain" in PubMed, Embase, Web of Science, ScienceDirect, and PsycINFO databases. A total of 117 studies met our inclusion criteria. We organized the results into a conceptual model with separate categories for biological and/or psychological and sociocultural and/or systems-level influences on HAs' pain experience, response to pain, and seeking and receiving pain care. We also included information on health care providers' experience of treating HA patients with pain. For each category, we identified future areas of research. We conclude with a discussion of limitations and clinical implications.

PERSPECTIVE

In this critical review of the literature we examined the pain and management experiences of the HA population. We propose a conceptual model, which highlights findings from the existing literature and future areas of research.

Nursing Unit Environment Associated with Provision of Language Services in Pediatric Hospices

BACKGROUND

Provision of language services in pediatric hospice enables nurses to communicate effectively with patients who have limited English proficiency. Language barriers contribute to ethnic disparities in health care. While language service use corresponds with improved patient comprehension of illness and care options, we lack an understanding of how the nurse work environment affects the provision of these services.

METHODS

Data were obtained from the 2007 National Home and Hospice Care Survey and included a study sample of 1251 pediatric hospice agencies. Variable selection was guided by structural contingency theory, which posits that organizational effectiveness is dependent upon how well an organization's structure relates to its context. Using multivariate logistic regression, we analyzed the extent to which nursing unit environment predicted provision of translation services and interpreter services.

RESULTS

The majority of hospices provided translation services (74.9 %) and interpreter services (87.1 %). Four variables predicted translation services: registered nurse (RN) unit size, RN leadership, RN medical expertise, and for-profit status. RN medical expertise and having a safety climate within the hospice corresponded with provision of interpreter services.

CONCLUSIONS

Findings indicate that nursing unit environment predicts provision of language services. Hospices with more specialized RNs and a stronger safety climate might include staffs who are dedicated to best care provision, including language services. This study provides valuable data on the nurse work environment as a predictor of language services provision, which can better serve patients with limited English proficiency and ultimately reduce ethnic disparities in end-of-life care for children and their families.

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

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

The Hispanic pharmacist: Value beyond a common language

Objective:

To highlight the added value of bilingual Hispanic pharmacists in the care of Hispanic patients by sharing their patients’ language and culture.

Summary:

Inability to speak and/or write in the patients’ native language severely impairs our best efforts to deliver good health care. This is a widely recognized cause of non-compliance or less than favorable possible health outcomes in Hispanic patients. What has received less attention, however, is that the ability to speak Spanish alone may not remove completely the barrier for non-compliance among Hispanics. Bilingual Spanish–English pharmacists do not have the language barrier, but if they do not recognize and accept cultural differences, their impact in their patients’ response may still be limited.

Conclusion:

It is time to recognize the added value of Hispanic pharmacists to Hispanic patients’ health outcomes. Understanding and sharing a culture allows the pharmacist to make medication education and interventions relevant to the patient and spark interest in their own health care. Thus, in caring for the health of our patients, cultural barriers may be more challenging to conquer than language barriers; deep appreciation and acceptance of our patients’ belief system cannot be acquired by just reading about it, having a computerized program, or hiring an interpreter.

Improving Coordination of Addiction Health Services Organizations with Mental Health and Public Health Services

In this mixed-method study, we examined coordination of mental health and public health services in addiction health services (AHS) in low-income racial and ethnic minority communities in 2011 and 2013. Data from surveys and semistructured interviews were used to evaluate the extent to which environmental and organizational characteristics influenced the likelihood of high coordination with mental health and public health providers among outpatient AHS programs. Coordination was defined and measured as the frequency of interorganizational contact among AHS programs and mental health and public health providers. The analytic sample consisted of 112 programs at time 1 (T1) and 122 programs at time 2 (T2), with 61 programs included in both periods of data collection. Forty-three percent of AHS programs reported high frequency of coordination with mental health providers at T1 compared to 66% at T2. Thirty-one percent of programs reported high frequency of coordination with public health services at T1 compared with 54% at T2. Programs with culturally responsive resources and community linkages were more likely to report high coordination with both services. Qualitative analysis highlighted the role of leadership in leveraging funding and developing creative solutions to deliver coordinated care. Overall, our findings suggest that AHS program funding, leadership, and cultural competence may be important drivers of program capacity to improve coordination with health service providers to serve minorities in an era of health care reform.

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

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

Disparity in cancer prevention and screening in aboriginal populations: recommendations for action

Historically, cancer has occurred at a lower rate in aboriginal populations; however, it is now dramatically increasing. Unless preventive measures are taken, cancer rates among aboriginal peoples are expected to soon surpass those in non-aboriginal populations. Because a large proportion of malignant disorders are preventable, primary prevention through socioeconomic interventions, environmental changes, and lifestyle modification might provide the best option for reducing the increasing burden of cancers. Such efforts can be further amplified by making use of effective cancer screening programs for early detection of cancers at their most treatable stage. However, compared with non-aboriginal Canadians, many aboriginal Canadians lack equal access to cancer screening and prevention programs. In this paper, we discuss disparities in cancer prevention and screening in aboriginal populations in Canada. We begin with the relevant definitions and a theoretical perspective of disparity in health care in aboriginal populations. A framework of health determinants is proposed to explain the pathways associated with an increased risk of cancer that are potentially avoidable. Major challenges and knowledge gaps in relation to cancer care for aboriginal populations are addressed, and we make recommendations to eliminate disparities in cancer control and prevention.

Pharmacist-patient communication barriers in dispensing practice: a descriptive study in Adama Hospital Medical College, Adama City, Oromia regional state, Ethiopia

Objectives

Drug dispensers should provide appropriate, understandable and relevant information to patient about their medication. But poor communication between patient and pharmacist carries potential adverse clinical consequences. Patients with inadequate literacy and/or health literacy skills are the most likely to have difficulties in understanding proper drug use. Our study is intended to assess the extent of pharmacist–patient communication barriers in dispensing.

Methods

This study was conducted in Adama Hospital Medical College, Adama City, Ethiopia, from March 2014 to May 2014. The survey data were collected both from pharmacists and patients through questionnaire and interview, respectively, and analysed manually by a data master sheet.

Key findings

A total of 345 outpatients who were collecting their medication from the Outpatient Department pharmacy and nine pharmacists were included in the study. 11.11% pharmacists utilised pictorial aid to their oral counselling. 77.78% of pharmacists can communicate in three languages (Amharic, Oromiffa and English). 20.87% of patients were geriatrics, 30.73% were illiterate and 34.20% were in low literacy. Misunderstanding of drug dose and frequency among illiterate and low literacy geriatric patients was 46.88%. 22.22% of geriatrics revisited the hospital for re-treatment of the same condition.

Conclusions

Counselling on dispensing is a fundamental step to enhance the patients’ rational use of medicine. When patients’ health is concerned, pharmacists should try their best to enhance the patient's understanding about medication use.

The stigma of mental illness in Arab families: a concept analysis

ACCESSIBLE SUMMARY

The stigma of mental illness varies significantly from culture to culture and from person to person. To date, little is known about how mental illness stigma manifests within the Arab community. This study aimed at bringing clarity to the concept of 'mental illness stigma' as it applies to Arab families. Nursing's holistic and patient-centered approach is integral to helping Arab patients and their families appropriately incorporate individual values, beliefs, and cultural perspectives into treatment plans. This study establishes a scientific alert for professionals at all levels to avoid making false generalizations about a specific culture that are not based on specific research findings from that culture.

ABSTRACT

Accessing mental health services is a critical step towards reducing the burden of mental illness. The stigma of mental illness is one of the most common reasons for not seeking mental health care leading to negative health consequences and undue suffering for many individuals and their families. Stigma is embedded in its social context. What may be considered acceptable in one society may be considered unacceptable and open to stigmatization in other societies. Arabs have a shared set of values, beliefs, and traditions that are substantially different from those of Westerners. Further, in most Arab countries, formal mental health resources are scarce and people with mental illness experience the compounded disadvantages of poverty and illness stigma. To date, little is known about how mental illness stigma manifests within the Arab community making it difficult to design and test interventions that support Arab individuals with mental illness and their families in treatment seeking and adherence. Using Rodger's concept analysis method, we examined how 'mental illness stigma' operates within an Arab context as a first step towards elucidating culturally competent approaches to treatment. This analysis provides a foundation for future work in the areas of mental illness diagnosis, education, and treatment that reflect the unique characteristics of Arab culture.

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

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

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

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

Does Race/Ethnicity or Socioeconomic Status Influence Patient Satisfaction in Pediatric Surgical Care?

OBJECTIVE

To evaluate patient satisfaction in outpatient pediatric surgical care and assess differences in scores by race/ethnicity and socioeconomic status (SES).

STUDY DESIGN

Observational, cross-sectional analysis.

SETTING

Outpatient pediatric surgical specialty clinics at a tertiary academic center.

SUBJECT AND METHODS

Families of patients received a patient satisfaction survey following their initial care visit in 2012. Mean scores were calculated and compared by child race/ethnicity and insurance type, where insurance with medical assistance (MA) served as a proxy for low SES. Kruskal-Wallis tests were used to compare scores between groups. Surveys were dichotomized to low and high scorers, and multivariate logistic regression was used to calculate the likelihood of high satisfaction.

RESULTS

Of 527 surveys completed, 132 (25%) were for children with MA and 143 (27%) were for racial/ethnic minority children. The overall satisfaction score for all specialties was 84.8, which did not significantly differ by SES (P = .98) or minority status (P = .52). The survey item with the highest score in both SES groups was "degree to which provider talked with you using words you could understand" (overall mean 91.94, P = .23). Multivariate analysis showed that patient age, sex, race/ethnicity, insurance type, neighborhood SES, neighborhood diversity, or surgical department did not significantly influence satisfaction.

CONCLUSION

This is the first study to evaluate the relationship between SES and race/ethnicity with patient satisfaction in outpatient pediatric surgical specialty care. In this analysis, no disparities were identified in the patient experience by individual- or community-level factors. Although the survey methodologies may be limited, these findings suggest that provision of care in pediatric surgical specialties can be simultaneously equitable, culturally competent, and family centered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Leadership and cultural competence of healthcare professionals: a social network analysis

BACKGROUND

International migration is a global phenomenon challenging healthcare professionals to provide culturally competent care.

OBJECTIVES

The purpose of this study was to investigate the influence of leaders on the cultural competence of healthcare professionals.

METHODS

A cross-sectional survey was conducted from 2010 to 2012 to obtain data for a social network analysis in 19 inpatient services and five primary care services in Belgium. The Competences in Ethnicity and Health questionnaire was used. A total of 507 healthcare professionals, including 302 nurses, identified their social relationships with other healthcare professionals working in their service. Highest in-degree centrality was used to identify the leaders within each health service. Multiple regressions with the Huber sandwich estimator were used to link cultural competence of leaders with the cultural competence of the rest of the healthcare staff.

RESULTS

Cultural competence of the healthcare staff was associated with the cultural competence of the leaders. This association remained significant for two specific domains of cultural competence-mediation and paradigm-after controlling for contextual and sociodemographic variables. Interaction analysis suggested that the leadership effect varied with the degree of cultural competence of the leaders.

DISCUSSION

Cultural competence among healthcare professionals is acquired partly through leadership. Social relationships and leadership effects within health services should be considered when developing and implementing culturally competent strategies. This requires a cautious approach as the most central individuals are not always the same persons as the formal leaders.

Development and psychometric assessment of the healthcare provider cultural competence instrument

This study presents the measurement properties of 5 scales used in the Healthcare Provider Cultural Competence Instrument (HPCCI). The HPCCI measures a health care provider's cultural competence along 5 primary dimensions: (1) awareness/sensitivity, (2) behaviors, (3) patient-centered communication, (4) practice orientation, and (5) self-assessment. Exploratory factor analysis demonstrated that the 5 scales were distinct, and within each scale items loaded as expected. Reliability statistics indicated a high level of internal consistency within each scale. The results indicate that the HPCCI effectively measures the cultural competence of health care providers and can provide useful professional feedback for practitioners and organizations seeking to increase a practitioner's cultural competence.

Diversity and inclusion training in pediatric departments

BACKGROUND AND OBJECTIVE

The diversifying US population of children necessitates assessing the diversity of the pediatric academic workforce and its level of cultural competency training. Such data are essential for workforce and educational policies.

METHODS

An 8-question survey was sent to 131 US pediatric chairs to assess plans for diversity, targeted groups, departmental diversity, diversity measures, perceived success in diversity, and presence and type of cultural competency training.

RESULTS

In all, 49.6% of chairs responded, and three-quarters of them reported having a plan for diversity, which targeted racial; ethnic; gender; lesbian, gay, bisexual, and transgender; disabled; and social class groups. Of the residents, 75% were women, as compared with 54% of faculty and 26% of chairs. Racial and ethnic diversity was limited among trainees, faculty, and leaders; <10% of each group was African American, Hispanic, or Native American. Asian Americans were more common among trainees (15%-33%) but were less common in faculty and leadership positions (0%-14%). Lesbian, gay, bisexual, and transgender physicians were represented in some groups. Measures of diversity included the number of trainees and faculty, promotion success, climate assessments, and exit interviews. Overall, 69% of chairs reported being successful in diversity efforts. A total of 90% reported cultural competency training for trainees, and 74% reported training for faculty and staff. Training in cultural competency included linguistic training, primarily in Spanish.

CONCLUSIONS

Pipeline issues for minorities are ongoing challenges. Pediatric leadership needs more representation of racial and ethnic minorities, women, and LGBT. Suggestions for workforce and educational policies are made.

Practice to research: integrating evidence-based practices with culture and context

There are ways to integrate culturally competent services (CCS) and evidence-based practices (EBP) which can improve the experiences of patients and their families and communities when faced with health problems, as well as the effectiveness and positive experiences of practitioners. CCS and EBP evidence should be jointly deployed for helping patients and clinicians. Partnership research models are useful for achieving the integration of CCS and EBP, since they involve close observation of and participation by clinicians and practitioners in the research process, and often use integrated qualitative and quantitative mixed methods. We illustrate this with 3 examples of work that can help integrate CCS and EBP: ongoing collection of information from patients, clinicians and staff, or "evidence farming"; close study and continuous improvement of activities and accommodations; and use of evidence of tacit, implicit cultural scripts and norms, such as being "productive," as well as explicit scripts. From a research practice point of view, collaborative partnerships will likely produce research with culture and context bracketed in, and will contribute stronger research models, methods, and units of analysis.

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

OBJECTIVE

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

DATA SOURCES/STUDY SETTING

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

DATA COLLECTION/EXTRACTION METHODS

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Is the Chronic Care Model Integrated Into Research Examining Culturally Competent Interventions for Ethnically Diverse Adults With Type 2 Diabetes Mellitus? A Review

The chronic care model (CCM) concerns both the medical and the cultural and linguistic needs of patients through the inclusion of cultural competence in the delivery system design. This literature review attempted to@@ identify the domains of the CCM culturally competent (CC) interventions that the adults from ethnic minorities suffering from type 2 diabetes mellitus report. We identified the CCM and the CC components in the relevant studies published between 2005 and 2014. Thirty-two studies were included. Thirty-one articles focused on self-management and 20 on community resources. Twenty-three interventions integrated cultural norms from the patients’ backgrounds. CC interventions reported the CCM at the individual level but need to address the organizational level more effectively. The scope of CC interventions should be expanded to transform health care organizations and systems.

A comparison of effectiveness of hepatitis B screening and linkage to care among foreign-born populations in clinical and nonclinical settings

Hepatitis B (HBV) is an urgent, unmet public health issue that affects Asian Americans disproportionately. Of the estimated 1.2 million living with chronic hepatitis B in USA, more than 50% are of Asian ethnicity, despite the fact that Asian Americans constitute less than 6% of the total US population. The Centers for Disease Control and Prevention recommends HBV screening of persons who are at high risk for the disease. Yet, large numbers of Asian Americans have not been diagnosed or tested, in large part because of perceived cultural and linguistic barriers. Primary care physicians are at the front line of the US health care system, and are in a position to identify individuals and families at risk. Clinical settings integrated into Asian American communities, where physicians are on staff and wellness care is emphasized, can provide testing for HBV. In this study, the Asian Health Coalition and its community partners conducted HBV screenings and follow-up linkage to care in both clinical and nonclinical settings. The nonclinic settings included health fair events organized by churches and social services agencies, and were able to reach large numbers of individuals. Twice as many Asian Americans were screened in nonclinical settings than in health clinics. Chi-square and independent samples t-test showed that participants from the two settings did not differ in test positivity, sex, insurance status, years of residence in USA, or education. Additionally, the same proportion of individuals found to be infected in the two groups underwent successful linkage to care. Nonclinical settings were as effective as clinical settings in screening for HBV, as well as in making treatment options available to those who tested positive; demographic factors did not confound the similarities. Further research is needed to evaluate if linkage to care can be accomplished equally efficiently on a larger scale.

Women's Perceptions of Provider Empathy in the Context of Healthcare Disparities

An issue in addressing racial healthcare disparities is the need to reduce, often unconscious, provider bias. Provider empathy can overcome such bias. Patient perceptions of provider empathy were explored to identify which provider behaviors patients perceived as conveying empathy and how perceived provider empathy influenced patient-provider interactions. In this qualitative study utilizing in-depth interviews and medical records, interviewers conducted in-depth interviews with 23 patients from three clinics. Patients reported that the following influenced perceptions of provider empathy: Taking time, patient engagement, valuing the patient, clear communication, and the healthcare system. Subtle racial differences existed. This information contributes to research on empathy and patient-provider interaction and provides preliminary evidence for racial differences.

Breast cancer treatment delays in a majority minority community: is there a difference?

PURPOSE

Recent studies from large nationwide cancer databases have consistently shown that Hispanic women with breast cancer have delays in treatment initiation compared with non-Hispanic white women. However, time to treatment initiation has not been studied in a community where Hispanics are the majority.

PATIENTS AND METHODS

We conducted a retrospective, observational study of 362 female patients with breast cancer treated at a large National Cancer Institute (NCI) -designated cancer center with a largely Hispanic population. We examined the relationship between race/ethnicity and time from mammogram to biopsy as well as time from biopsy to treatment initiation using Kaplan-Meier analyses and multivariable Cox proportional hazards regression.

RESULTS

Half of the female patients with breast cancer were of Hispanic descent (50.0%; n = 181). Hispanic patients were more likely to be obese, have an Eastern Cooperative Oncology Group functional status ≥ 1, and have higher histologic grade disease (all P ≤ .05); no differences in American Joint Committee on Cancer stage at diagnosis were observed. After comprehensive adjustment for demographic and clinical characteristics, we found no significant differences between Hispanic versus non-Hispanic white patients in time from mammogram to biopsy (hazard ratio [HR], 0.91; 95% CI, 0.68 to 1.21) or time from biopsy to treatment (HR, 1.13; 95% CI, 0.69 to 1.88).

CONCLUSION

Hispanic women and Non-Hispanic white women with breast cancer treated at an NCI-designated cancer center had similar times to biopsy and treatment initiation. These findings suggest that in majority minority communities with large cancer centers, racial disparities can be reduced. With a growing Hispanic population throughout the United States, future studies should examine the long-term impact on improved breast cancer survival in this population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

"Only your blood can tell the story"--a qualitative research study using semi-structured interviews to explore the hepatitis B related knowledge, perceptions and experiences of remote dwelling Indigenous Australians and their health care providers in northern Australia

BACKGROUND

Hepatitis B is endemic in the Indigenous communities of the Northern Territory of Australia and significantly contributes to liver-related morbidity and mortality. It is recognised that low health literacy levels, different worldviews and English as a second language all contribute to the difficulties health workers often have in explaining biomedical health concepts, relevant to hepatitis B infection, to patients. The aim of this research project was to explore the knowledge, perceptions and experiences of remote dwelling Indigenous adults and their health care providers relating to hepatitis B infection with a view to using this as the evidence base to develop a culturally appropriate educational tool.

METHODS

The impetus for this project came from health clinic staff at a remote community in Arnhem Land in the Northern Territory, in partnership with a visiting specialist liver clinic from the Royal Darwin Hospital. Participants were clinic patients with hepatitis B (n = 12), community members (n = 9) and key informants (n = 13); 25 were Indigenous individuals.A participatory action research project design was used with purposive sampling to identify participants. Semi-structured interviews were undertaken to explore: current understanding of hepatitis B, desire for knowledge, and perspectives on how people could acquire the information needed. All individuals were offered the use of an interpreter. The data were examined using deductive and inductive thematic analysis.

RESULTS

Low levels of biomedical knowledge about Hepatitis B, negative perceptions of Hepatitis B, communication (particularly language) and culture were the major themes that emerged from the data. Accurate concepts grounded in Indigenous culture such as "only your blood can tell the story" were present but accompanied by a feeling of disempowerment due to perceived lack of "medical" understanding, and informed partnerships between caregiver and patient. Culturally appropriate discussions in a patient's first language using visual aids were identified as vital to improving communication.

CONCLUSIONS

Having an educational tool in Indigenous patient's first language is crucial in developing treatment partnerships for Indigenous patients with hepatitis B. Using a culturally appropriate worldview as the foundation for development should help to reduce disempowerment and improve health literacy.

Am I My Brother's Keeper? African American Men's Health Within the Context of Equity and Policy

African American men's health has at times been regarded as irrelevant to the health and well-being of the communities where they are born, grow, live, work, and age. The uniqueness of being male and of African descent calls for a critical examination and deeper understanding of the psycho-socio-historical context in which African American men have lived. There is a critical need for scholarship that better contextualizes African American Male Theory and cultural humility in terms of public health. Furthermore, the focus of much of the social determinants of health and health equity policy literature has been on advocacy, but few researchers have examined why health-related public policies have not been adopted and implemented from a political and theoretical policy analysis perspective. The purpose of this article will be to examine African American men's health within the context of social determinants of health status, health behavior, and health inequalities-elucidating policy implications for system change and providing recommendations from the vantage point of health equity.

Physician and Family Recommendations to Obtain a Mammogram and Mammography Intentions: The Moderating Effects of Perceived Seriousness and Risk of Breast Cancer

A growing body of literature has demonstrated psychosocial factors enable mammography intentions and usage among Latinas. Although these factors (e.g., family recommendations, breast cancer perceptions) likely influence one another, little research has examined interactive effects. The current study assessed the moderating effect of perceived breast cancer seriousness and risk on associations between recommendations to obtain mammography and mammography intentions. This sample included 97 Latinas in rural Eastern Washington State. After adjusting for age, two significant interactions emerged: perceived seriousness × physician recommendation and perceived risk × family recommendation. This exploratory study provides important directions for future communication research and planning to improve screening disparities.

Nursing Assistants’ Communication Styles in Korean American Older Adults With Dementia

As ethnic diversity increases in the United States with the anticipated increase in dementia, it is critical to understand the implications of dementia and culturally appropriate communication for ethnic minority older adults with dementia. Utilizing the Ethno-Cultural Gerontological Nursing model and the Progressively Lowered Stress Threshold model, this article describes the relationship between nursing assistants’ communication style and behavioral symptoms of dementia, focused on Korean American older adults with dementia residing in nursing homes. The discussion includes reviewing currently available studies, nursing implications, and suggestions for future studies.

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

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

Adaptation of health care for migrants: whose responsibility?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

African American women's perceptions of cancer clinical trials

Cancer clinical trials are important for resolving cancer health disparities for several reasons; however, clinical trial participation among African Americans is significantly lower than Caucasians. This study engaged focus groups of 82 female African American cancer survivors or cancer caregivers, including those in better resourced, more urban areas and less resourced, more rural areas. Informed by an integrated conceptual model, the focus groups examined perceptions of cancer clinical trials and identified leverage points that future interventions may use to improve enrollment rates. Study findings highlight variation in community knowledge regarding cancer clinical trials, and the importance of community education regarding clinical trials and overcoming historical stigma associated with clinical research specifically and the health care system more generally. Study participants commented on the centrality of churches in their communities, and thus the promise of the church as loci of such education. Findings also suggested the value of informed community leaders as community information sources, including community members who have a previous diagnosis of cancer and clinical trial experience. The sample size and location of the focus groups may limit the generalizability of the results. Since the women in the focus groups were either cancer survivors or caregivers, they may have different experiences than nonparticipants who lack the close connection with cancer. Trust in the health system and in one's physician was seen as important factors associated with patient willingness to enroll in clinical trials, and participants suggested that physicians who were compassionate and who engaged and educated their patients would build important trust requisite for patient participation in clinical trials.

Community health center provider and staff's Spanish language ability and cultural awareness

Many community health center providers and staff care for Latinos with diabetes, but their Spanish language ability and awareness of Latino culture are unknown. We surveyed 512 Midwestern health center providers and staff who managed Latino patients with diabetes. Few respondents had high Spanish language (13%) or cultural awareness scores (22%). Of respondents who self-reported 76-100% of their patients were Latino, 48% had moderate/low Spanish language and 49% had moderate/low cultural competency scores. Among these respondents, 3% lacked access to interpreters and 27% had neither received cultural competency training nor had access to training. Among all respondents, Spanish skills and Latino cultural awareness were low. Respondents who saw a significant number of Latinos had good access to interpretation services but not cultural competency training. Improved Spanish-language skills and increased access to cultural competency training and Latino cultural knowledge are needed to provide linguistically and culturally tailored care to Latino patients.

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

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

Cultural Competence Models and Cultural Competence Assessment Instruments in Nursing

The author reviewed cultural competence models and cultural competence assessment instruments developed and published by nurse researchers since 1982. Both models and instruments were examined in terms of their components, theoretical backgrounds, empirical validation, and psychometric evaluation. Most models were not empirically tested; only a few models developed model-based instruments. About half of the instruments were tested with varying levels of psychometric properties. Other related issues were discussed, including the definition of cultural competence and its significance in model and instrument development, limitations of existing models and instruments, impact of cultural competence on health disparities, and further work in cultural competence research and practice.

Evaluation of the organizational cultural competence of a community health center: a multimethod approach

Cultural competence is an important component of client-centered care in health promotion and community health services, especially considering the changing demographics of North America. Although a number of tools for evaluating cultural competence have been developed, few studies have reported on the results of organizational cultural competence evaluations in health care or social services settings. This article aims to fill this gap by providing a description of a cultural competence evaluation of a community health center serving a diverse population. Data collection included reviewing documents, and surveying staff, management, and the Board of Directors. The organization fully met 28 of 53 standards of cultural competence, partially met 21 standards, and did not meet 2 standards, and 2 standards could not be assessed due to missing information. The advantages and lessons learned from this organizational cultural competence evaluation are discussed.

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

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

Interventions to improve cultural competency in healthcare: a systematic review of reviews

Background

Cultural competency is a recognized and popular approach to improving the provision of health care to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities. The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field to form a comprehensive understanding of the current evidence base that can guide future interventions and research in the area.

Methods

A systematic review of review articles published between January 2000 and June 2012 was conducted. Electronic databases (including Medline, Cinahl and PsycINFO), reference lists of articles, and key websites were searched. Reviews of cultural competency in health settings only were included. Each review was critically appraised by two authors using a study appraisal tool and were given a quality assessment rating of weak, moderate or strong.

Results

Nineteen published reviews were identified. Reviews consisted of between 5 and 38 studies, included a variety of health care settings/contexts and a range of study types. There were three main categories of study outcomes: patient-related outcomes, provider-related outcomes, and health service access and utilization outcomes. The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilization outcomes but weaker evidence for improvements in patient/client outcomes.

Conclusion

This review of reviews indicates that there is some evidence that interventions to improve cultural competency can improve patient/client health outcomes. However, a lack of methodological rigor is common amongst the studies included in reviews and many of the studies rely on self-report, which is subject to a range of biases, while objective evidence of intervention effectiveness was rare. Future research should measure both healthcare provider and patient/client health outcomes, consider organizational factors, and utilize more rigorous study designs.

Cultural identity and patient trust among older American Indians

BACKGROUND

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

OBJECTIVE

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

DESIGN

Patient survey administered following primary care visits.

PARTICIPANTS

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

MAIN MEASURES

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

KEY RESULTS

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

CONCLUSIONS

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