Research Commentary [25] November 2018

Oct 12, 2018

Addressing health workforce cultural competence is a common approach to improving health service quality for culturally and ethnically diverse groups. This research commentary focuses on the research evidence on cultural competency training and its effects on practitioners’ knowledge, attitudes, skills and behaviour. The articles reviewed report on the intervention strategies, outcomes, and measures included the studies with the purpose of informing the implementation and evaluation of future interventions to improve health workforce cultural competence.

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

The following articles are reviewed:

Article 1: How to measure cultural competence when evaluating patient-centred care: a scoping review

The purpose of this study was to identify patient-centred quality indicators (PC-QI) and measures for measuring cultural competence in healthcare. Monitoring and evaluating patient-centred care for ethnocultural communities allows for improvements to be made in the delivery of culturally competent healthcare. 

The review identified a vast body of research on cultural competence in PCC. Most indicators found in the review were structure and process indicators. The presence of structure indicators for cultural competence is vital in building the foundation for process and outcome indicators. 

This review is the first to examine PCC QIs for assessing cultural competence in healthcare. Measuring cultural competence and PCC through indicators is necessary to ensure that patients are receiving quality care that is sensitive to their healthcare needs. Importantly, the identified measures found in this review provide the potential foundation for the development of indicators to assess cultural competence in PCC. Indicators should be presented as percentages or proportions, to guide monitoring of healthcare quality.

Health quality organisations such as the AHRQ, Health Quality Ontario and other quality improvement agencies use percentages or proportions as the unit of measurement for quality improvement.This unit of measurement allows for comparison across facilities and facilitates longitudinal evaluation, measuring care that is truly culturally competent, and patient centred. Indicators are often derived from measures. Measures such as the CAHPS CC Item Set (Weech-Maldonado, Carle et al., 2012)and the CCATH (Weech-Maldonado, Dreachslin et al., 2012)are validated measures, and are potential data sources for the development of indicators.

References: 

Weech-Maldonado, R., Carle, A., Weidmer, B., et al. (2012). The Consumer Assessment of Healthcare Providers and Systems (CAHPS) cultural competence (CC) item set. Med Care, 50(9 Suppl 2), S22–31.

Publication: https://www.ncbi.nlm.nih.gov/pubmed/22895226

Weech-Maldonado, R., Dreachslin, J.L., Brown, J, et al. (2012). Cultural competency assessment tool for hospitals: evaluating hospitals' adherence to the culturally and linguistically appropriate services standards. Health Care Manage Rev, 37, 54–66.

Publication: https://www.ncbi.nlm.nih.gov/pubmed/21934511

Authors: Ahmed, S., Siad, F.M., Manalili, K., et al.

Citation: Ahmed, S., Siad, F.M., Manalili, K., et al. (2018).How to measure cultural competence when evaluating patient-centred care: a scoping review. BMJ Open 2018; 8:e021525. doi:10.1136/ bmjopen-2018-021525

Publication: https://bmjopen.bmj.com/content/8/7/e021525

Article 2: Health workforce cultural competency interventions: a systematic scoping review

This systematic scoping review was completed as part of a larger systematic literature search conducted on cultural competence intervention evaluations in health care in Canada, the United States, Australia and New Zealand published from 2006 to 2015. Overall, 64 studies on cultural competency interventions were found, with 16 aimed directly at the health workforce.

There was significant heterogeneity in workforce intervention strategies, measures and outcomes reported across studies making comparisons of intervention effects difficult. The two main workforce intervention strategies identified were cultural competency training and other professional development interventions including other training and mentoring. Positive outcomes were commonly reported for improved practitioner knowledge (9/16), skills (7/16), and attitudes/beliefs (5/16). Although health care (6/16) and health (2/16) outcomes were reported in some studies there was very limited evidence of positive intervention impacts. Only four studies utilised existing validated measurement tools to assess intervention outcomes. 

Approximately half of the studies reviewed used a “categorical” approach to cultural competency which involves teaching health providers information about particular cultural, ethnic groups. Such approaches describe common health beliefs, attitudes and behaviours of particular groups and offer prescriptive advice about what to do and what not to do in clinical encounters. Categorical approaches risk stereotyping patients and families which can increase cultural misunderstanding. Such approaches have also been criticised for giving little attention to intra-group variability and for failing to account for the ways in which acculturation and socioeconomic status effect different individual’s ways of expressing and experiencing their culture. As the authors state “ to avoid generalisations which may lead to cultural misunderstanding, a more suitable tactic is to learn as much as possible directly from patients about their own sociocultural perspectives and how they see this impacting their encounters with healthcare practitioners” (p.11)

Another key approach to cultural competence education and training which addresses some of the concerns identified with categorical approaches is the cross-cultural approach. This latter approach is used in all eCALD courses. A cross-cultural approach to cultural competence education and training is focused on teaching general knowledge, attitudes and skills relevant to navigating any cross-cultural situation. These skills and attitudes include: eliciting patients’ explanatory models of health issues and their causes; strategies for negotiating shared understanding and facilitating participatory decision-making in creating treatment plans; and understanding health and illness in its bio psychosocial context. As well as being applicable in clinical encounters with patients from varied cultural and ethnic backgrounds, such approaches have the advantage of being focused on specific skills that can be applied in healthcare encounters.

To establish the relative impacts of different approaches to cultural competence training, comparative evaluations of interventions are needed to assess impacts using the same measurement instruments. Given the level of heterogeneity in cultural competency training interventions, a tool to assess the themes, concepts, methods and learning objectives of training interventions, would contribute greatly towards the comparison of outcomes between interventions. To facilitate greater analysis and comparison of cultural competency training approaches, it is important that evaluations provide sufficient detail on training approaches and content.  

Authors: Jongen, C., McCalman, J. & Bainbridge, R.

Citation: Jongen, C., McCalman, J. & Bainbridge, R. (2018). Health workforce cultural competency interventions: a systematic scoping review. BMC Health Services Research, 18, 232. https://doi.org/10.1186/s12913-018-3001-5

Publication: https://link.springer.com/content/pdf/10.1186%2Fs12913-018-3001-5.pdf

Article 3:  Assessing explanatory models and health beliefs: essential but overlooked as a competency for clinicians

Mental health services have over the years tried to address cultural diversity in a number of ways. Historically, ethnic matching between patients and clinicians within mainstream services has been one of the most commonly proposed solutions to the problem cast as cultural misunderstanding of normative behaviours, misdiagnosis and poor treatment adherence. A second common strategy has been to resort to culture-specific services, mainly through voluntary sector provisions of ethnic-specific services. I agree with the authors when they argue that such approaches do not translate to any improvement in the cultural capability of the general workforce.

Explanatory models can and should be an integral part of both cultural adaptations and cultural competence: not only can they provide health professionals and researchers with culture- and context-specific information, to the benefit of diagnostic accuracy, but more importantly they provide them with more fine grained information about subcultural beliefs and values, for the purposes of both research and clinical outcomes assessment. 

Explanatory models need to become an integral part of the DSM assessment framework in order to avoid a classification system that is either too Western-centric or that uses a Western-centric ideology to classify culture-bound syndromes. A culturally sensitive clinical approach based on the exploration of explanatory models during assessment and treatment is an effective way of dealing with the complexity of patients’ and families’ needs by putting culture and narratives at the forefront of care. This requires clinicians to be open to considering their own culturally held beliefs and the influence of these on their preferred paradigms of assessment and treatment.

Authors: Dinos, S., Ascoli, M.,Owiti², J.A. & Bhui, K.  

Citation: Dinos, S., Ascoli, M.,Owiti, J.A. & Bhui, K. (2017). Assessingexplanatorymodelsandhealthbeliefs:essentialbutoverlooked asacompetencyforclinicians.BJPsych Advances, 23, 106–114. doi: 10.1192/apt.bp.114.013680

Publication: https://www.researchgate.net/publication/316628708_Assessing_explanatory_models_and_health_beliefs_An_essential_but_overlooked_competency_for_clinicians

Article 4:  Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature

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

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

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

The domains of the mental health performance measures for administrative and service entities  and more recent CCATH for application in hospitals (Weech-Maldonado, Dreachslin et al., 2012) suggest that important outcome measures are: the cultural competence of clinical/health care (including consumer representation and care delivery), human resource management  including workforce diversity and training), translation and interpretation services, and organisational commitment, leadership and data management and quality improvement systems. The findings of this review suggested that also useful are measures of the health outcomes from interventions and broader research translation to effect national or jurisdictional policies related to cultural competence in healthcare. Documented measures (eg Weech-Maldonado, Dreachslin et al., 2012) are currently based on the perceptions of healthcare managers/administrators who are likely to have the required information to complete them (Weech-Maldonado, Carle et al. et al., 2012); however, given the importance of user engagement, there is a strong case for incorporation of patient perspectives in evaluating the cultural competence of healthcare interventions. 

References: 

Weech-Maldonado, R., Carle, A., Weidmer, B., et al. (2012). The Consumer Assessment of Healthcare Providers and Systems (CAHPS) cultural competence (CC) item set. Med Care, 50(9 Suppl 2), S22–31.

Publication: https://www.ncbi.nlm.nih.gov/pubmed/22895226

Weech-Maldonado, R., Dreachslin, J.L., Brown, J, et al. (2012). Cultural competency assessment tool for hospitals: evaluating hospitals' adherence to the culturally and linguistically appropriate services standards. Health Care Manage Rev, 37, 54–66.

Publication: https://www.ncbi.nlm.nih.gov/pubmed/21934511

Authors: McCalman, J., Jongen, C. & Bainbridge, R.

Citation: McCalman, J., Jongen, C. & Bainbridge, R. (2017). Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature. Int J Equity Health. 16(1), 78. doi: 10.1186/s12939-017-0571-5.

Publication: https://www.ncbi.nlm.nih.gov/pubmed/28499378