Improving Cultural Competence to Reduce Health Disparities [Entered Retrospectively]

Project Summary Title and Description

Title
Improving Cultural Competence to Reduce Health Disparities [Entered Retrospectively]
Description
Objective. To examine existing system-, clinic-, provider-, and individual-level interventions to improve culturally appropriate health care for people with disabilities; lesbian, gay, bisexual, and transgender (LGBT) populations; and racial-ethnic minority populations. Data sources. Ovid MEDLINE®, PsycINFO®, Ovid Embase®, and the Cochrane EPOC; hand searches of references of relevant studies. Review methods. Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and other observational studies with comparators that evaluated cultural competence interventions aimed at reducing health disparities in the formal healthcare system. Two investigators abstracted data and assessed risk of bias. Given the sparse and patchy literature that precluded pooling, a qualitative analysis is provided. Results. Over 37,000 nonduplicated, English language citations were reviewed; 56 unique studies were identified as of June, 2015: 20 RCTs and five observational studies for individuals with disabilities; five RCTs (six manuscripts) and six observational studies for LGBT populations; and 14 RCTs (15 manuscripts), four observational studies, and two systematic reviews for members of racial and ethnic minorities. Interventions fell into four broad categories: (1) provider trainings and education; (2) interventions providing alteration of an established protocol, or the delivery of an established protocol, to meet the needs of a target population; (3) interventions prompting patients to interact with the formal health care system or health care providers; and (4) interventions aimed at providing culturally competent care at the point of service. Educational programs and trainings to improve professional students’ and providers’ cultural competence behavior is the most prevalent type of cultural competence intervention. Two existing, high quality systematic reviews of provider educational interventions for racial/ethnic minority populations found low-strength evidence that cultural competence training had mixed effects for intermediate outcomes and no effect on treatment outcomes. Sixteen studies aimed at changing provider attitudes and beliefs through training or curricula were identified for the disability population. Eleven of these studies focused on reducing professional stigma toward people with serious or chronic mental illness; five focused on changing professional attitudes and beliefs about people with physical or intellectual disability. Three educational interventions were identified for the LGBT population. Several short-term effects were evaluated; however, long-term effects of provider training on provider cultural competence behavior in the clinical setting and subsequent patient health outcomes have not been evaluated for the disability and LGBT populations. Two included studies reported a potential harm from provider training, an increase in negative attitudes, or stigma resulting from intervention. Interventions providing alterations of an established protocol were concentrated in the racial/ethnic minority populations. The 12 studies of culturally tailored health care interventions for racial/ethnic minority populations focused primarily on treatment of chronic physical or mental health conditions (e.g., diabetes, depression, substance abuse). Two psychological interventions were also tailored for members of the LGBT population. Another common type of intervention was to provide additional resources to encourage or empower patients to interact with the formal health care system and/or health care providers. The stated aims of these types of interventions were to increase receipt of screenings for which disparities are well-documented (e.g., papanicolaou tests for people with mobility impairments or colorectal cancer screening among Latino immigrants), or to help patients engage in medical decisionmaking. These studies met inclusion criteria if the intervention was conducted by a medical professional in a formal health care system. One potential limitation of these types of interventions is that they rely on strong identification with a common culture. The population groups highlighted in this review are large and diverse. Creating an intervention for “African Americans” or “women who have sex with women” may be differentially effective for specific subpopulations. The most common culturally competent point of service interventions were documents, similar to a handheld medical record, that patients carried to their appointments to prompt providers to evaluate areas of known disparity for a specific population. These interventions may be coupled with provider notices or trainings. Virtual interventions were also considered culturally competent point of service interventions for some people with disabilities, as they create access in a unique way. These interventions are seen as conceptually parallel to infrastructure changes that improve access for people with physical disabilities. For the majority of included studies, the risk of bias was high. The most common methodological problems were: lack of randomization to treatment; lack of attention control; little or no followup; and failure to report unintended consequences. Large segments of vulnerable or disadvantaged populations, such as children with disabilities, people who may be gender nonconforming or transgender, or numerous racial or ethnic groups, including Native Americans or Alaskan Natives, remain essentially invisible in the cultural competence literature. This is compounded for people who are members of more than one priority population. Conclusions. None of the included studies measured the effect of cultural competence interventions on health care disparities. Most of the training interventions measured changes in professional attitudes toward the population of interest, but did not measure the downstream effect of changing provider beliefs on the care delivered to patients. Interventions that altered existing protocols, empowered patients to interact with the formal health care system, or prompted provider behavior at the point of care were more likely to measure patient-centered outcomes. The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way. The term cultural competence is not well defined for the LGBT and disability populations, and is often conflated with patient-centered or individualized care. There are many gaps in the literature; many large subpopulations are not represented.
Attribution
N/A
Authors of Report
N/A
Methodology description
N/A
PROSPERO
N/A
DOI
10.7301/Z0T43R04
Notes
Web address not yet available. Entered retrospectively. Word tables include basic study characteristics of included studies, quality assessment, and outcomes extracted.
Funding Source
AHRQ

Key Questions

1. What models have been used to conceptualize cultural competence and culturally appropriate care in health contexts, and how do those models compare?
2. What is the effectiveness of interventions to improve culturally appropriate care for LGBT adolescents (ages 13-17), young adults (18-25), and adults? A. 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 B. 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 C. 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 D. Adverse events; unintended negative consequences of intervention
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
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
5. What is the effectiveness of organizational or structural interventions for promoting culturally appropriate care for each of the priority populations across providers?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

TitleAuthorsYear
A controlled trial of mental illness related stigma training for medical students.2011
Changing attitudes about persons with disabilities: effects of a simulation.1998
A curriculum on care for people with disabilities: effects on medical student self-reported attitudes and comfort level.2014
The outcomes of an intervention study to reduce the barriers experienced by people with intellectual disabilities accessing primary health care services.2006
Evaluating the impact of direct and indirect contact on the mental health stigma of pharmacy students.2012
Filmed v. live social contact interventions to reduce stigma: randomised controlled trial.2012
Antitumour immune response and cancer vaccination: the critical role of dendritic cells.1999
Reducing medical students' stigmatization of people with chronic mental illness: a field intervention at the "living museum" state hospital art studio.2012
Anti-stigma training for medical students: the Education Not Discrimination project.2013
Reducing the stigma of mental illness in undergraduate medical education: a randomized controlled trial.2013
Impact of mental health first aid training on pharmacy students' knowledge, attitudes and self-reported behaviour: a controlled trial.2011
Effectiveness of contact-based education for reducing mental illness-related stigma in pharmacy students.2012
Assessing the impact of training on mental health nurses' therapeutic attitudes and knowledge about co-morbidity: a randomised controlled trial.2007
Changing stigma through a consumer-based stigma reduction program.2014
A wheelchair workshop for medical students improves knowledge and skills: a randomized controlled trial.2011
Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: a randomised clinical trial.2011
Improving cancer screening among women with mobility impairments: randomized controlled trial of a participatory workshop intervention.-- Not Found --
Effects of a comprehensive health assessment programme for Australian adults with intellectual disability: a cluster randomized trial.2007
Does information about patients who are intellectually disabled translate into better cooperation during dental visits?-- Not Found --
Intervening to improve communication between parents, teachers, and primary care providers of children with ADHD or at high risk for ADHD.2005
Long-term effects of an internet-based treatment for posttraumatic stress.2010
Randomized trial of a teleconference-delivered fatigue management program for people with multiple sclerosis.2011
RAHelp: an online intervention for individuals with rheumatoid arthritis.2013
The early detection of Lewis carcinoma by using a new experimental histochemical method.1990
An Evaluation of the Implementation of Hand Held Health Records with Adults with Learning Disabilities: A Cluster Randomized Controlled Trial2010
Evaluating a lesbian and gay health care curriculum.2002
The Mpowerment Project: a community-level HIV prevention intervention for young gay men.1996
The Treatment Advocacy Program: a randomized controlled trial of a peer-led safer sex intervention for HIV-infected men who have sex with men.2010
Routine brief risk-reduction counseling with biannual STD testing reduces STD incidence among HIV-infected men who have sex with men in care.2012
Impact of a computer-assisted, provider-delivered intervention on sexual risk behaviors in HIV-positive men who have sex with men (MSM) in a primary care setting.2013
Sustained reductions in drug use and depression symptoms from treatment for drug abuse in methamphetamine-dependent gay and bisexual men.2005
Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men.2005
Psychosocial intervention for lesbians with primary breast cancer.-- Not Found --
Effects of breast cancer risk counseling for sexual minority women.2006
A behavioural intervention to reduce persistence of bacterial vaginosis among women who report sex with women: results of a randomised trial.2011
Teaching social and cultural awareness to medical students: "it's all very nice to talk about it in theory, but ultimately it makes no difference".2003
A critical intervention in lesbian, gay, bisexual, and transgender health: knowledge and attitude outcomes among second-year medical students.-- Not Found --
A randomized controlled trial of a multilevel intervention to increase colorectal cancer screening among Latino immigrants in a primary care facility.
A social psychological approach to improving the outcomes of racially discordant medical interactions.2013
Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: the BRIDGE Study.
Activation, self-management, engagement, and retention in behavioral health care: a randomized clinical trial of the DECIDE intervention.2014
Evaluation of a patient activation and empowerment intervention in mental health care.2008
Implementing Ask Me 3 to improve African American patient satisfaction and perceptions of physician cultural competency.2010
Intervention to improve follow-up for abnormal Papanicolaou tests: a randomized clinical trial.2014
Comparing culturally accommodated versus standard group CBT for Latino adolescents with substance use disorders: a pilot study.2012
The effect of a diabetes education, coping skills training, and care intervention on physiological and psychosocial outcomes in black women with type 2 diabetes.2010
A Culturally Adapted Smoking Cessation Intervention for Korean Americans: A Mediating Effect of Perceived Family Norm Toward Quitting.2015
Adapted cognitive behavioral group therapy for depressed low-income African American women.2002
Culturally adapted motivational interviewing for Latino heavy drinkers: results from a randomized clinical trial.2013
Familias Sanas: an intervention designed to increase rates of postpartum visits among Latinas.2010
Culturally adapted versus standard exposure treatment for phobic Asian Americans: Treatment efficacy, moderators, and predictors.2011
An HIV prevention intervention for ethnically diverse men in substance abuse treatment: pilot study findings.2013
One-year postcollaborative depression care trial outcomes among predominantly Hispanic diabetes safety net patients.-- Not Found --
Characterization of factors affecting attainment of glycemic control in Asian Americans with diabetes in a culturally specific program.-- Not Found --
Interventions to improve cultural competency in healthcare: a systematic review of reviews.
Usual source of care and unmet health care needs: interaction of disability with race and ethnicity.2014
Culturally Tailored Smoking Cessation for Adult American Indian Smokers A Clinical Trial2014
A developmental model of ethnosensitivity in family practice training.-- Not Found --
Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model.2000
A model and instrument for addressing cultural competence in health care.1999
Integrating cultural humility into health care professional education and training.2012
The cultural mosaic: a metatheory for understanding the complexity of culture.2005
A curriculum for multicultural education in family medicine.-- Not Found --
Of goldfish tanks and moonlight tricks: can cultural competency ameliorate health disparities?-- Not Found --
Cultural competence in the era of evidence-based practice.-- Not Found --
What do non-English-speaking patients value in acute care? Cultural competency from the patient's perspective: a qualitative study.2008
Helping health and social care professionals to develop an 'inequalities imagination': a model for use in education and practice.2003
Conceptualizing and critiquing culture in health research.2004
Diet counseling in a multicultural society.-- Not Found --
Anthropology in the clinic: the problem of cultural competency and how to fix it.2006
Leininger's theory of nursing: cultural care diversity and universality.1988
Disability disparities: a beginning model.2009
A taxonomy for developing cultural competence.1999
A model for cultural competency in the HIV management of African American patients.2003
Transcultural mental health nursing. 2: Race, ethnicity and culture.-- Not Found --
The Purnell Model for Cultural Competence.2002
A crash-course in cultural competence.2006
Culturally congruent care: putting the puzzle together.2007
Providing culturally appropriate care: a literature review.2010
A teaching framework for cross-cultural health care. Application in family practice.1983
The Latino Patient: A cultural guide for health care providers2002
Toward a culturally competent system of care, volume 1: a monograph on effective services for minority children who are severely emotionally disturbed
Transcultural nursing: Assessment and intervention
ETHNIC: a framework for culturally competent clinical practice. In Appendix: useful clinical interviewing mnemonics.2000
Transcultural Care: a guide for health care professionals1998
The fifteen minute hour: applied psychotherapy for the primary care physician. 2nd ed.

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