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Butler M, McCreedy E, Schwer N, et al. Improving Cultural Competence to Reduce Health Disparities [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Mar. (Comparative Effectiveness Reviews, No. 170.)
Background
The U.S. health care system needs to reduce health disparities and achieve better equity for patients. Culturally competent care is seen as foundational for reducing disparities. Culturally competent care respects diversity as well as the cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.1 The Office of Minority Health, Department of Health and Human Services, has established national standards for culturally and linguistically appropriate services (CLAS) in health and health care (National CLAS Standards). These provide a blueprint for implementing appropriate services to improve health care in the United States.2 The standards cover governance, leadership, workforce, communication and language assistance, organizational engagement, continuous improvement, and accountability.
A lack of conceptual clarity around cultural competence persists both in practice and among researchers. Cultural competence is defined, conceptualized, and operationalized in a variety of ways. This variance leads to disagreement around the training needed for providers to attain cultural competence.3 The populations to which the term cultural competence applies are also ill-defined. Often, the term cultural competence is applied only to racial and ethnic minority populations. This narrow application omits other marginalized groups who may be ethnically and racially similar to a provider but nonetheless at risk for stigmatization or discrimination, or who have differences in health care needs that result in health disparities. This broader concept may be termed “diversity competence.” In keeping with this broader view, this systematic literature review considers three populations experiencing health disparities in the U.S. health system: individuals with disabilities; lesbian, gay, bisexual, and transgender (LGBT) populations; and racial and ethnic minority populations. These groups are not mutually exclusive; the cultural competence movement continues to evolve in response to an increasingly multicultural society.
In addition to provider education and training, changing clinical environments can also be key to improving culturally competent care. Changes in provider knowledge, attitudes, and skills are necessary, but for those gains to translate into culturally competent behaviors the structures and culture of health care systems and organizations must also change. This review focuses on the effectiveness of interventions at the provider and system level. Policy level interventions are important, but beyond the scope of this review.
Interpretation and significance of outcomes differ by priority population. Access is important to all priority populations. However, individuals with disabilities may face multiple barriers, such as transportation to facilities and accessibility of exam rooms and their contents. Similarly, linguistic competence means something different in relation to a person for whom English is not his/her first language compared with a person with an expressive communication limitation who uses an augmentative communication system or a person who may be gender nonconforming or transgender.
The concept of cultural competence overlaps with several other concepts related to providing high-quality, appropriate care. Figure 1 illustrates a few of these overlapping concepts. Conducting a systematic review requires clarity about whether interventions fall inside or outside of the inclusion criteria. The criteria are built to provide a specified scope of cultural competence. For this review, we focus mainly on whether cultural competency interventions change the clinicians' attitudes or behaviors (e.g., stereotypes, communication and clinical decisionmaking), the patient-provider relationship, and/or clinical systems to result in better outcomes for patients from the populations of interest. This review focuses on interventions that promote equity, thus the primary outcomes of interest are reductions in disparities between populations for a given health outcome measure.
Includable interventions that lie within the cultural competence circle in Figure 1 are defined as:
- Interventions that take place at the system level, engineering a system that prompts physicians to pay attention to areas of known disparity, such as interventions prompting equitable receipt of preventive care or chronic disease.
- Interventions that address physical barriers to access.
- Interventions that improve the ability of providers to provide health care services to patients from a population of interest. Targeted providers can include physicians, nursing staff, allied health professionals, paraprofessionals, and clinic staff who have regular contact with patients, or health system factors intended to engineer the system to support and sustain cultural competence.
- Interventions that help providers better understand cultural components of clinical encounters with different populations and their own inherent biases.
- Interventions that assist patients from a population of interest to competently navigate the patient-provider relationship and the larger health system
As the overlapping circles in Figure1 suggest, some interventions targeted at meeting underserved needs fall outside our scope, such as interventions to address access problems due to finance/insurance coverage issues (such as Medicare/Medicaid), individualized or patient-centered care that is not culturally tailored (such as implementing a medical home model or a computer-assisted cancer risk assessment for all patients), and general patient health literacy interventions that are not provided by a health care professional or do not track patient interactions with the formal health care system. Some public health outreach activities, such as community-based HIV education in underserved African American neighborhoods, or school-based empowerment programs for young people with disabilities, may also address an unmet need. However, given our focus on the patient-provider interaction and the system of care surrounding that interaction, such studies are not included in this review. Within the clinical context, interventions aimed at improving care for all patients (such as patient-centered care), are excluded unless the intervention is specifically tailored to one of this review's populations of interest.
Report Organization
This report is organized in several chapters. The next sections of this introductory chapter present the Key Questions, analytic framework, and brief overview of study selection methods for the three populations of interest. Following this introductory chapter, we present the systematic reviews conducted for each of the populations. Each of these chapters are intended to stand alone for readers interested in specific priority populations. Chapter 2 presents the systematic review of literature for the disability populations, while Chapters 3 and 4 present the reviews for the LGBT communities and the racial and ethnic minorities, respectively. The report concludes with Chapter 5, a review of the models that have contributed to different conceptualizations of cultural competence, and an overarching discussion of cross-cutting themes identified in the reviews in Chapters 2-4.
Key Questions and Analytic Framework
The Key Questions (KQs); the populations, interventions, comparators, outcomes, timing, and settings (PICOTS); and analytic framework, developed with input from key informants, were posted for public comment from February 6, 2014, to February 26, 2014.
KQ 1: What models have been used to conceptualize cultural competence and culturally appropriate care in health contexts, and how do those models compare?
KQ 2: What is the effectiveness of interventions to improve culturally appropriate care for LGBT adolescents (ages 13-17), young adults (18-25), and adults?
- Provider intermediate outcomes
- Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes
- Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization
- Improved specific knowledge of health needs unique to LGBT community
- Provider behavior, such as clinical decisionmaking, communication
- Patient intermediate outcomes
- Patient learning/knowledge, including linguistic competence regarding gender-diversity
- Improved access to health services
- Utilization of health services
- Patient experience and satisfaction, such as improved perceptions of care
- Patient health behaviors, such as tobacco use or health seeking behaviors
- Use of preventive services
- Final health or patient-centered health outcomes, including but not limited to:
- Improved mental health outcomes, such as depression, anxiety, suicidality, peer/familial/intimate relationships, substance use
- Improved medical health outcomes, such as reduction in obesity, improved sexual health
- Adverse events; unintended negative consequences of intervention
KQ 3: What is the effectiveness of interventions to improve culturally appropriate health care for children and adults with disabilities?
- E.
Provider intermediate outcomes
- Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes, willingness to serve and perceived competence for people with disabilities
- Provider behavior, such as clinical decisionmaking and communication
- Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization
- F.
Patient intermediate outcomes
- Improved access to health services
- Utilization of health services
- Patient experience and satisfaction, such as improved perceptions of care
- G.
Final health or patient-centered health outcomes, including but not limited to:
- Improved mental health outcomes, such as depression, substance use
- Improved medical health outcomes, such as reduction in obesity, metabolic disorders, heart disease, breast cancer
- Patient health behaviors, such as tobacco use or health seeking behaviors
- Use of preventive services, and other access to care measures
- H.
Adverse effects; unintended negative consequences of interventions
KQ 4: What is the effectiveness of interventions to improve culturally appropriate health care for racial/ethnic minority children and adults?
- I.
Provider intermediate outcomes
- Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes, willingness to serve and perceived competence for racial/ethnic minority children and adults
- Provider behavior, such as clinical decisionmaking, communication
- Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization
- J.
Patient intermediate outcomes
- Patient beliefs/attitudes such as improved trust, perceived racism
- Utilization of health services
- Patient experience and satisfaction, such as improved perceptions of care
- Patient health behaviors, such as tobacco use or health-seeking behaviors
- Use of preventive services, and other access to care measures
- K.
Final health or patient-centered health outcomes, including but not limited to:
- Improved mental health outcomes, such as depression, substance use
- Improved medical health outcomes, such as reduction in obesity, kidney disease, heart disease, breast cancer, sickle cell disease
- L.
Adverse effects; unintended negative consequences of interventions
KQ 5: What is the effectiveness of organizational or structural interventions for promoting culturally appropriate care for each of the priority populations across providers?
Table 1 provides the PICOTS by the Key Questions, and Figure 2 shows the analytic framework.
Methods Overview
Because each of the populations of interest is categorically different from the others, unique search algorithms, inclusion/exclusion criteria, and decision rules for identifying the included literature set were established for each population. Figure 3 illustrates the hierarchy used to identify relevant studies. In the screening process, all the populations of interest were similar in that the study design needed to test an intervention that was part of the formal health care system (e.g., located at clinic, led by nurse, or treatment of a specific health condition that could be delivered within the formal health care system) and that it went beyond framing the study as addressing a health disparity by using an intervention explicitly tailored to be more culturally competent. For the disability and LGBT populations, studies that passed through screening to this level were included. Because the racial/ethnic minority populations have a longer history of cultural competence interventions, we further required that the study explicitly tested the cultural competency component of the intervention.
Studies that specifically addressed cultural competence varied in the degree to which interventions were tailored to incorporate key components of cultural competence and the directness of the test of culturally competent health care. For racial/ethnic minority populations, we excluded interventions in which cultural tailoring was limited to language translation, patient-provider concordance, or culturally-tailored media (e.g., brochures, videos). The intervention had to be designed to improve cultural competence of the health care system. Only translating or adding multicultural features to materials was not sufficient.
We anticipated sufficient literature to apply full systematic review methods including possible meta-analysis. Anticipated methods were outlined in the protocol. However, given the paucity of literature identified using systematic review search methods, the heterogeneity of the study populations and interventions, small study samples, the lack of details for complex interventions and comparators, and the high risk of bias assessment for most of the included studies, we determined the strength of evidence for cultural competence interventions, in general, to be insufficient, and thus we were unable to draw meaningful conclusions from the literature. Therefore, results are summarized in evidence tables and qualitatively synthesized by common characteristics of interventions and outcome measures. Barriers to forming inferences from study results are also presented. Where we were able to use previously published systematic reviews that evaluated strength of evidence, we report that review's strength of evidence finding.
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