Research Commentary [10] August 2017

Aug 2, 2017

The focus of this review is on evidence for the effectiveness of Culturally and Linguistically Diverse (CALD) Cultural Competency Training for improving patient satisfaction and patient outcomes for the CALD populations. 

The New Zealand Medical Journal last month published the findings of a New Zealand Patient Satisfaction Study which showed that after controlling for various demographic and psychological factors Māori, Pacific and Asian groups had lower satisfaction rates with healthcare access than European New Zealanders (Lee & Sibley, 2017). Nearly 72 per cent of European respondents were highly satisfied compared to 61 per cent for Māori, 62 per cent for Asian and 63 per cent for Pacific peoples.  This result can be linked to findings that CALD groups are more likely to experience language, information and cultural barriers to healthcare, and the lack of cultural competence among health professionals (Ministry of Health, 2008; Wong, 2015).

eCALD® Services Culturally and Linguistically Diverse (CALD) cultural competence training for the health workforce focuses on enhancing cultural awareness, attitudes, knowledge and skills to improve understanding and responsiveness to cultural differences between practitioners and patients. The CALD cultural competence training informs practitioners about patient cultures and prepares them for complex interventions involving cross-cultural communication skills, exploration of barriers to care, and managing sensitive cultural issues.

References:

Lee, C.H.J. & Sibley, C. (2017). Demographic and psychological correlates of satisfaction with healthcare access in New Zealand. New Zealand Medical Journal, 130, (1459), 11-24. Retrieved from: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459-21-july-2017

Ministry of Health (2008). A Portrait of Health. Key Results of the 2006/7 New Zealand Health survey. Wellington: Ministry of Health. Retrieved from: https://www.health.govt.nz/system/files/documents/publications/portrait-of-health-june08.pdf

Wong, A. (2015). Challenges for Asian health and Asian health promotion in New Zealand. Auckland: Health promotion Forum of New Zealand. Retrieved from: http://www.hauora.co.nz/assets/files/Occasional%20Papers/15128%20%20FINAL%20%20Health%20promotion%20forum%20Asian%20promotion%20article.pdf

Commentary provided by Dr Annette Mortensen, eCALD® Project Manager: Research & Development

The following are articles reviewed:

Article 1:  Demographic and psychological correlates of satisfaction with healthcare access in New Zealand.

Using a nationally representative sample of New Zealand adults, the study investigated people’s satisfaction with their access to healthcare when needed. The study assessed the distribution of people’s satisfaction with their healthcare access and examined its association with a broad range of demographic and psychological factors. The findings of the analyses reveal group inequalities in healthcare access. Over two-thirds of New Zealanders (68.4%) were highly satisfied with their access to healthcare when needed, while 25.3% were moderately satisfied and 6.1% expressed low satisfaction. This indicates that more than a quarter of New Zealanders express some degree of dissatisfaction in their healthcare access. Such dissatisfaction can be linked to a wide range of factors, including difficulty making appointments, transport, costs and perceptions of unfair treatment (Jansen & Smith, 2006; Jansen et al., 2008; Ministry of Health, 2008; Statistics New Zealand and Ministry of Pacific Island Affairs, 2011; Wong, 2015).

The results revealed considerable ethnic differences in levels of satisfaction with healthcare access. Relative to Europeans, ethnic minorities exhibited a higher rate of low satisfaction (4.8% versus 6.3–11.0%) and a lower rate of high satisfaction (71.8% versus 61.1–63.4%). After controlling for various demographic and psychological factors, Māori, Pacific and Asian peoples were found to express lower satisfaction with their healthcare access than Europeans. This result can be linked to findings that ethnic minorities are more inclined to experience language, information and cultural barriers to healthcare, and the lack of cultural competence among medical professionals (Jansen & Smith, 2006; Jansen et al., 2008; Ministry of Health, 2016; Statistics New Zealand and Ministry of Pacific Island Affairs, 2011; Wong, 2015). In order to increase healthcare access for ethnic minorities, it is essential to train the health workforce in CALD cultural competence and to develop tailored health interventions that target the unique cultural barriers encountered by culturally diverse groups. 

Authors: Ministry of Health 

Citation: Lee, C.H.J. & Sibley, C. (2017). Demographic and psychological correlates of satisfaction with healthcare access in New Zealand. New Zealand Medical Journal, 130, (1459), 11-24. Retrieved from: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459-21-july-2017

References:

Jansen, P., Bacal, K. & Crengle, S. (2008). He Ritenga Whakaaro: Māori experiences of health services. Hospital, 200, 30–7. Retrieved from: https://www.nzdoctor.co.nz/media/6399/He-Ritenga-Whakaaro.pdf

Jansen, P. & Smith, K. (2006). Maori experiences of primary health care. NZFP,  33, 298–300. Retrieved from: http://www.members.mauriora.co.nz/wp-content/uploads/2015/03/JansenOct06-NZFP.pdf 

Ministry of Health (2016). Annual Update of Key Results 2015/16: New Zealand Health Survey. Wellington: Ministry of Health. Retrieved from: http://www.health.govt.nz/system/files/documents/publications/annual-update-key-results-2015-16-nzhs-dec16-v2.pdf 

Ministry of Health (2008). A Portrait of Health. Key Results of the 2006/7 New Zealand Health Survey. Wellington: Ministry of Health. Retrieved from: https://www.health.govt.nz/system/files/documents/publications/portrait-of-health-june08.pdf

Wong, A. (2015). Challenges for Asian health and Asian health promotion in New Zealand. Auckland: Health promotion Forum of New Zealand. Retrieved from: http://www.hauora.co.nz/assets/files/Occasional%20Papers/15128%20%20FINAL%20%20Health%20promotion%20forum%20Asian%20promotion%20article.pdf

Statistics New Zealand and Ministry of Pacific Island Affairs (2011). Health and Pacific peoples in New Zealand. Wellington: Statistics New Zealand and Ministry of Pacific Island Affairs. Retrieved from: http://www.stats.govt.nz/browse_for_stats/people_and_communities/pacific_peoples/pacific-progress-health.aspx

Article 2: Cultural competence education for health professionals. 

A Cochrane Collaboration review assessed the effects of cultural competence education for health professionals (Horvat et al., 2014). Five Randomised Controlled Trials (RCTs) were included involving 337 health professionals (including general practitioners, primary care teams and counsellors) and 8400 patients. Three studies were conducted in the USA, one in Canada and one in The Netherlands. At least 3000 patients were from culturally and linguistically diverse (CALD) backgrounds and some of the health professional groups were also from CALD backgrounds. Involvement in care improved in one study in the Netherlands measuring mutual understanding between CALD patients and their doctors. Health behaviour also changed in one study in the USA, in which women whose counsellors had received education were three times more likely to attend planned counselling sessions. Health behaviour (client concordance with attendance) improved significantly among intervention participants compared with controls in an American study.  The review findings showed support for cultural competence education for health professionals (Horvat et al., 2014). 

The Cochrane Collaboration review demonstrates that cultural competence training has expected beneficial outcomes through increased cultural understanding and skills which leads to potential beneficial outcomes, including increased patient satisfaction; Improved adherence to treatment and Improved health outcomes.

Authors: Horvat, L., Horey, D., Romios, P., Kis-Rigo, J.

Citation: Horvat, L., Horey, D., Romios, P., Kis-Rigo, J. (2014). Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, 5,  Art. No. CD009405.

Publication

Article 3: The effectiveness of cultural competence programs in ethnic minority patient-centered health care—a systematic review of the literature.

The purpose of this review was to examine the effectiveness of patient-centered care models, which incorporate a cultural competence perspective, in improving health outcomes among culturally and linguistically diverse (CALD) patients.

There were 13 studies that met the inclusion criteria for this review. Overall, the authors found evidence supporting the effectiveness of cultural competence, patient-centered care model training in increasing knowledge levels, self-reported practice and patient satisfaction. However, whereas increases in cultural knowledge and awareness were evident, no studies reported any significant findings in terms of patient health outcomes. Only two studies used this variable as an outcome measure, and both of these studies were hampered by participant attrition or small sample sizes and short intervention periods. Importantly, the fact that most of the research on cultural competence, patient-centered care model programmes measured effectiveness in terms of practitioner knowledge and not patient health represents a major shortcoming to the current research on this topic, as patient health outcome is one of, if not the most important indicator of effectiveness of any care model. Thus, the current results in this regard are limited, and more research is required to properly assess the impact of the reviewed interventions on patient health.

Authors: Renzaho, A.M.N., Romios, P., Crock, C. & SØnderlund, A.L.

Citation: Renzaho, A.M.N., Romios, P., Crock, C. & SØnderlund, A.L. (2013). The effectiveness of cultural competence programs in ethnic minority patient centered health care—a systematic review of the literature. International Journal for Quality in Health Care, 25 (3), 261–269.

Publication

Article 4: Interventions to improve cultural competency in healthcare: a systematic review of reviews.

Cultural competency training is a recognised and popular approach to improving the provision of health care to culturally and linguistically diverse groups with the aim of reducing ethnic health disparities. The aim of this systematic review of reviews was to gather and synthesise 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.

The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilisation outcomes. However, a lack of methodological rigour was 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 reviews should be explicit about their definition or framework of cultural competency and what constitutes a culturally competent intervention, whether at the individual-level, organisational-level or systemic-level. Reviews should also examine multiple outcomes at all three levels where possible due to the multi-dimensional nature of cultural competency interventions and the complexities in translating cultural competency into practice. Further development and assessment of organisational cultural competency models and assessment tools is needed.

The authors recommend that multi-level interventions should consider the different contexts (e.g. government policy vs. community issues) and cultures (e.g. individual vs. organisational) that can affect the implementation and success of interventions to improve cultural competency. Issues related to organisational change and understanding the mechanisms by which health innovations are adopted should also be taken into account. There is also need for research to examine the time and resources required to implement interventions in addition to identifying the most feasible and effective approaches. This is particularly important for organisational and systemic approaches where cost-benefit/effectiveness is an important consideration. In summary, future research should measure both healthcare provider and patient/client health outcomes, consider organisational factors, and utilise more rigorous study designs.

Authors: Truong, M., Paradies, Y. & Priest, N.

Citation: Truong, M., Paradies, Y. & Priest, N. (2014). Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Services Research, 14, 99. 

Publication

Article 5: A meta-analysis of educational interventions designed to enhance cultural competence in professional nurses and nursing students.

The purpose of this project was to synthesise studies that implemented a programme to increase cultural competence in nursing students and professional nurses. A total of 25 studies were included in the review. The studies were coded for relevant characteristics in addition to estimating an effect size of the programme's impact. Because of the divergent nature of the effect sizes, two meta-analyses were conducted. The results of the pre-test to post-test synthesis indicated a statistically significant, moderate programme effect. The results of the treatment–control synthesis indicated a non-statistically significant, yet positive programme effect. The results of the moderator analyses for the pre-test to post-test effect size revealed that funded, peer-reviewed studies were likely to show larger programme impacts. The moderator analyses for treatment–control studies indicated significantly larger effects for samples of practicing nurses as well as funded studies. Given the implications cultural competence has for patients, the results of this meta-analysis have implication for nursing training. The results held across multiple designs in addition to settings, dosages, and measures.

The failure to agree upon a model and definition for cultural competence is an obstacle to developing, implementing, and evaluating the effectiveness of these educational interventions. The term cultural competence is used interchangeably with cultural sensitivity, cultural awareness, cultural proficiency, cultural congruency and cultural intelligence. Effective learning methods and their subsequent evaluation cannot be achieved without clear and precise explanation of the cultural competence construct (Betancourt et al., 2003; Capell et al., 2007). However, the results of this synthesis indicate potential for cultural competence training to lead to greater awareness and that awareness to potential patient benefits.

Authors: Gallagher R.W. & Polanin, J.R.

Citation: Gallagher R.W. & Polanin, J.R. (2015).  A meta-analysis of educational interventions designed to enhance cultural competence in professional nurses and nursing students. Nurse Education Today, 35 (2), 333-340.

References:

Betancourt, J.R., Green, A.R., Carillo, J.E., Ananeh-Firempong, O. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities. Public Health Rep, 118, 293–302. 

Capell, J., Veenstra, G. & Dean, E. (2007). Cultural competence in healthcare: critical analysis of the construct, its assessment and implications. J. Theory Constr Test, 11, 30–37. 

Publication