) Culture Competency a Systemic Review of Health Care Provider Educational Interventions
Med Care. Author manuscript; available in PMC 2011 Jul 15.
Published in final edited form as:
PMCID: PMC3137284
NIHMSID: NIHMS297600
Cultural Competency: A Systematic Review of Health Intendance Provider Educational Interventions
Mary Catherine Beach
*Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Academy
†Segmentation of Full general Internal Medicine, Department of Medicine, Johns Hopkins Academy School of Medicine
‡Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
§Phoebe R. Berman Bioethics Found, Johns Hopkins Academy
Eboni G. Price
†Division of General Internal Medicine, Department of Medicine, Johns Hopkins University Schoolhouse of Medicine
Tiffany L. Gary
*Welch Heart for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University
¶Department of Epidemiology, Johns Hopkins Bloomberg Schoolhouse of Public Health
Karen A. Robinson
†Partition of General Internal Medicine, Department of Medicine, Johns Hopkins University Schoolhouse of Medicine
Aysegul Gozu
†Division of Full general Internal Medicine, Department of Medicine, Johns Hopkins University Schoolhouse of Medicine
Ana Palacio
†Division of General Internal Medicine, Section of Medicine, Johns Hopkins University Schoolhouse of Medicine
Carole Smarth
‖Partition of Infectious Diseases, Section of Medicine, Johns Hopkins Schoolhouse of Medicine, Baltimore, Maryland
Mollie W. Jenckes
†Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine
Carolyn Feuerstein
†Sectionalisation of General Internal Medicine, Section of Medicine, Johns Hopkins University School of Medicine
Eric B. Bass
†Division of General Internal Medicine, Department of Medicine, Johns Hopkins Academy School of Medicine
‡Department of Wellness Policy and Management, Johns Hopkins Bloomberg School of Public Health
¶Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
Neil R. Powe
*Welch Centre for Prevention, Epidemiology, and Clinical Enquiry, Johns Hopkins University
†Partition of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine
‡Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Wellness
¶Department of Epidemiology, Johns Hopkins Bloomberg School of Public Wellness
Lisa A. Cooper
*Welch Centre for Prevention, Epidemiology, and Clinical Enquiry, Johns Hopkins University
†Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine
‡Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Wellness
Abstract
Objective
Nosotros sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals.
Pattern
This was a systematic literature review and analysis.
Methods
Nosotros performed electronic and manus searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a earlier- and an after-intervention evaluation or had a control grouping for comparison and graded the strength of the show equally splendid, proficient, fair, or poor using predetermined criteria.
Main Consequence Measures
We sought evidence of the effectiveness and costs of cultural competence training of health professionals.
Results
Xxx-four studies were included in our review. There is excellent evidence that cultural competence grooming improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial upshot), and expert evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial result and xiv of 14 studies evaluating skills demonstrated a beneficial event). There is good evidence that cultural competence training impacts patient satisfaction (3 of three studies demonstrated a benign effect), poor evidence that cultural competence preparation impacts patient adherence (although the i written report designed to practice this demonstrated a beneficial upshot), and no studies that accept evaluated patient health condition outcomes. In that location is poor show to determine the costs of cultural competence training (5 studies included incomplete estimates of costs).
Conclusions
Cultural competence preparation shows promise every bit a strategy for improving the knowledge, attitudes, and skills of wellness professionals. All the same, testify that it improves patient adherence to therapy, wellness outcomes, and disinterestedness of services across racial and indigenous groups is lacking. Time to come inquiry should focus on these outcomes and should determine which education methods and content are nearly effective.
Keywords: race/ethnicity, health disparities, cultural competence
Racial and indigenous disparities in the quality of health care take been extensively documented,one and information technology has been suggested that cultural competence on the part of wellness care providers and organizations may be one mechanism to reduce racial and ethnic disparities in care.2 Cultural competence has been defined as "the power of individuals to establish effective interpersonal and working relationships that supersede cultural differences"3 past recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account.iv
In anticipation of the hope of cultural competence training, the Part of Minority Health has put forth standards for cultural competence that include training of wellness intendance providers,5 and the Accreditation Council on Graduate Medical Education (ACGME) has required that physicians-in-grooming demonstrate sensitivity and responsiveness to a patient's culture equally part of its professionalism competency.six Despite the promise of cultural competency training, there has been little systematic evaluation of its potential bear on.
The purpose of this study was to conduct a systematic review of the literature of interventions designed to meliorate the cultural competence of health care providers. Our specific aims were to determine (1) what strategies accept been shown to ameliorate the cultural competence of healthcare providers and (2) what the costs of these strategies are.
METHODS
Study Design
We conducted a systematic review of the literature to address the broad question of which strategies to improve the quality of care for racial/ethnic minorities are effective. We chose to behave a systematic review rather than a meta-analysis because of the anticipated heterogeneity in the literature. To that cease, we used formal methods of literature identification, selection of relevant articles, data abstraction, quality cess, and synthesis of results to review literature on the effectiveness and costs of cultural competence grooming for healthcare providers.
In February 2003, nosotros searched (1) MEDLINE®, (two) the Cochrane Key Register of Controlled Trials (Issue 1, 2003), (iii) EMBASE, (4) the specialized annals of Effective Practice and Organization of Care Cochrane Review Grouping (EPOC), (5) the Research and Development Resource Base in Continuing Medical Teaching (RDRB/CME), and (6) the Cumulative Alphabetize of Nursing and Allied Health Literature (CINAHL®). We designed search strategies, specific to each database, to maximize sensitivity. Initially, we developed a core strategy for MEDLINE, accessed via PubMed, based on an assay of the Medical Discipline Headings (MeSH) and text words of fundamental articles identified a priori. The PubMed strategy, which used terms such equally "cultural sensitivity," "transcultural," "cultural diversity," and "multicultural" as well as "cultural competency," formed the basis for the strategies adult for the other electronic databases.7
In addition to electronic searching, we identified priority journals that had provided the most citations in the electronic searching, and we scanned their tables of contents from February 1, 2003, through June 15, 2003. We likewise scanned the reference lists of primal review articles and all articles eligible for our report. The results of the searches were downloaded and imported into ProCite, a reference management software program. This database was used to store citations, track search results and sources, and rail the abstract and commodity review process.
Eligibility Criteria
The following criteria were used to exclude manufactures from further consideration: published prior to 1980, non in English, did not include human data, contained no original information, a meeting abstract only (no full article for review), not relevant to minority wellness, no intervention, intervention not targeted to healthcare providers or organizations, no evaluation of the intervention, inconclusive evaluation of the intervention (intervention evaluated only with a post-examination), or commodity did non apply to any of the study questions.
We printed the title and abstract of all citations identified through the literature search, and two team members independently reviewed the title and abstract for eligibility. Because reviewer agreement was predictable to be depression (calculated kappa was 0.41 on a random sample of abstracts), we designed our process such that no abstract would be excluded based on the stance of only one reviewer. When reviewers agreed that a decision regarding eligibility could not be made considering of insufficient information, the full commodity was retrieved for review. When reviewers disagreed on eligibility, citations were returned for arbitrament by reviewers until they reached understanding. Reviewers were asked to err on the side of inclusion.
Article Review
Nosotros developed standardized review forms to (1) confirm eligibility for full article review, (2) assess study characteristics, and (3) extract the relevant data to address the written report questions. The forms were adult through an iterative process that included review of forms used for previous systematic reviews, discussions among team members and experts, and pilot testing.
For each eligible study, nosotros abstracted data regarding the targeted providers and setting, curricular content (using a previously published framework that included general cultural concepts, specific cultural content, linguistic communication, racism, admission issues, doctor-patient interactions, socioeconomic status and gender/sexuality),eight teaching methods, evaluation methods, and outcomes. We classified outcomes as either provider outcomes (knowledge, attitudes/beliefs, or skills/ behaviors) or patient outcomes (satisfaction, adherence, and health condition). We also designed several questions to assess methodological strengths and weaknesses of studies, specifically including written report design and objectivity of upshot assessment. Objective outcome assessments included written tests and standardized instruments, whereas event assessments that were not considered objective included open up-concluded interviews and learner self-cess.
We conducted contained and serial reviews of the quality assessment forms from 10 articles to calculate the agreement betwixt reviewers. Each quality assessment course contained 21 questions with 3–iv possible choices. We found a mean kappa (beyond the 21 items) of 0.81 for the independent review procedure and 0.87 for the serial review process. These values are like and in the range that most experts would consider splendid agreement.9 We used a serial review process to conserve time and resources. A main reviewer completed the quality assessment and data abstraction forms and a 2d reviewer, afterward reading the commodity, checked each detail on the course for abyss and accuracy. Differences between principal and secondary reviewers were resolved by adjudication and, when necessary, consultation and consensus with the entire team of reviewers.
Data Synthesis
We created summary tables of evidence from these studies and then examined the relation betwixt various intervention characteristics and outcomes beyond studies. In particular, we examined the outcomes of interventions according to several features of the interventions that we determined would be of interest to educators and policy makers: intervention length (for those at the extremes of ≤ 1 twenty-four hour period and ≥ 1 week), curricular content (those that taught general concepts of culture, those that focused on specific cultures, and those that did both), and curricular method (those that used experiential learning, which was divers equally either cultural immersion, clinical experience or interviewing members of another civilization, and those that did not apply whatever of those methods).
Evidence Grading
Once all articles were reviewed and information were synthesized, the strength of the evidence supporting each outcome type was graded into iv categories (grades A through D) based on its quality, quantity, and consistency. We adult the evidence grading scheme based on proposed criteria.10 For quality, we used 2 criteria: written report design and the presence of objective cess. To encounter the quality criteria for form A, there must have been at least one randomized controlled trial and at least 75% of the studies must have used an objective assessment method. To meet grade B, there must accept been at least one controlled trial (not necessarily randomized) AND at to the lowest degree 50% of studies must have had objective assessment. To run across grade C or D, there did not need to be whatsoever controlled trials and < 50% of studies could have had objective assessment.
For quantity of studies, there had to be at least 4 studies to meet criteria for grade A, three studies to come across criteria for grade B, ii studies to meet criteria for grade C, or at least 1 study to meet criteria for grade D. For consistency, the results of the studies had to be consistent (either beneficial or harmful results in same direction across almost all studies) to meet criteria for grade A, reasonably consequent to meet criteria for grade B (most study results in the same management), and inconsistent to encounter criteria for grade C. If there were likewise few studies to judge the consistency of results, the strength of evidence supporting the question was given a course of D. The grading of the evidence was discussed at squad meetings (particularly to determine the consistency) and consensus was reached on each criterion. The bear witness received a final "grade" that reflected the lowest rank on any of the iv criteria (two for quality and 1 each for quantity and consistency).
RESULTS
A total of 34 articles met eligibility criteria.xi–44 Figure 1 describes the literature review and search procedure. The eligible articles are summarized in Table 1 and described in detail in Table two. Studies on cultural competence training are increasing in frequency. Virtually have used a pre/post evaluation pattern, have occurred in the United States, and have targeted physicians and/or nurses. A multifariousness of curricular methods and content has been evaluated, although no ii studies take evaluated exactly the aforementioned curriculum.
Summary of literature search and review procedure (number of manufactures). 1From reference lists of eligible and central manufactures likewise as tables of contents of the following journals: Academic Medicine Athenaeum of Pediatric and Adolescent Medicine Ethnicity and Disease Health Services Research Periodical of the American Medical Association Journal of General Internal Medicine Journal of Health Care for the Poor and Underserved Journal of Transcultural Nursing Medical Intendance Milbank Quarterly New England Journal of Medicine, and Pediatrics. 2The most common reasons for exclusion at the full article review level were that the article lacked evaluation of the described intervention, the commodity was not relevant to minority health, or the commodity was not targeted to health care provider or organization. Thirty articles were excluded because the intervention was only evaluated with a postintervention evaluation.
TABLE 1
Summary of 34 Studies Evaluating Interventions to Improve Cultural Competence Training of Health Professionals
| north | |
|---|---|
| Dates | |
| 1980–89 | 4 |
| 1990–99 | 15 |
| > 2000 | 15 |
| Study design | |
| RCT | 2 |
| Controlled | 12 |
| Pre/Post | xx |
| Setting | |
| United states | 29 |
| Non-United states of america | v |
| Targeted learners* | |
| Physicians | xviii |
| Nurses | 17 |
| Learner level | |
| Preprofessional | 22 |
| Practicing professional | 11 |
| Curricular content* | |
| Specific cultures | 26 |
| Full general concepts | xix |
| Linguistic communication | ten |
| Dr-pt interaction | 8 |
| Access | 3 |
| Racism | 2 |
| SES | 2 |
| Curricular methods* | |
| Lectures | 17 |
| Discussion (group) | 17 |
| Example scenarios | 12 |
| Clinical experience | 10 |
| Small group | nine |
| Cultural immersion | viii |
| Audio/visual | 7 |
| Interviewing other cultures | 7 |
| Function play | 5 |
| Targeted cultures (if specified)* | |
| African American | 10 |
| American Indian | 0 |
| Asian/Pacific Islander | 10 |
| Latino | 9 |
| Contact time (if specified) | |
| Less than viii hours | xi |
| Between 1–5 days | 5 |
| Greater than 1 week | ix |
| Effect type* | |
| Provider cognition | 19 |
| Provider mental attitude | 25 |
| Provider skills/behaviors | 14 |
| Patient satisfaction | 3 |
| Outcome assessment | |
| Objective | 26 |
| Not objective | viii |
TABLE 2
Description of 34 Studies Evaluating Interventions to Improve Cultural Competence Training of Wellness Professionals
| Writer, Yr | Study Design | Grooming Level | Curricular Content | Specific Civilisation | Contact Time | Curricular Methods |
|---|---|---|---|---|---|---|
| Studies on physicians | ||||||
| Mao, 1988 | Pre/postal service | Pre-prof | GC, D-P, SC, | NS | I four-hour session held in one case only | Audio/visual, discussion (group) |
| Copeman, 1989 | Pre/post | Pre-prof | R, D-P, Fifty, SC | Aboriginal | NS | Case scenarios, clinical experiences, word (group), interviewing members of another civilisation |
| Rubenstein, 1992 | Pre/post | Pre-prof | GC, SC | A/PI | I 4-hour session held in one case only | Case scenarios, give-and-take (group), interviewing members of some other civilisation, lectures |
| Nora, 1994 | pre/post (external control) | Pre-prof | L, SC, A | H | 30 2-hour sessions plus 8 days total time | Clinical experiences, culture immersion, demonstration/part modeling, discussion (group), language lessons, lectures, food shopping/planning, infirmary tours, cultural and history learning |
| Culhane-Pera, 1997 | Pre/post | R/F | GC, D-P, L, SC | H | 3 1-solar day sessions | Audio/visual, clinical experiences, discussion (group), drill/practice exercise, lectures |
| Farnill, 1997 | Pre/post | Pre-prof | L | Not-English-speaking persons | 16 < two- hour sessions held over 7 months | Discussion (grouping), interviewing members of another culture |
| Haq, 2000 | Pre/post | Pre-prof, R/F | GC, SC | A/PI, AA, H | 8–10 weeks total fourth dimension | Brainstorming, case scenarios, clinical experiences, culture immersion, discussion (group), drill/practice exercise, lectures, conduction of community wellness activities |
| Dogra, 2001 | Pre/post | Pre-prof | GC | NS | Ii 2-hour sessions in 1 week | Brainstorming, case scenarios, drill/practice practise, lectures |
| Godkin, 2001 | CCT | Pre-prof | GC, Fifty, SC, SES | A/PI, H | Xxx one-half-24-hour interval sessions over 1 year plus half-dozen weeks total-time | Civilization immersion, interviewing members of another civilization, language lessons, lectures, community service |
| Mazor, 2002 | Pre/post | R/F, prof | 50, SC | H | 2-hr sessions held weekly for 10 weeks | Case scenarios, language lessons |
| Tang, 2002 | Pre/post | Pre-prof | NS | NS | Sessions held over 4 years | Case scenarios, lectures |
| Beagan, 2003 | Mail service just (external control) | Pre-prof | L, SC | NS | 1 afternoon each week held over 2 years | Clinical experiences, lectures |
| Crandall, 2003 | Pre/post | Pre-prof | GC, R, SC, SES | NS | Twenty 2–3 hour sessions held over 1 year | Audio/visual, case scenarios, demonstration/role modeling, interviewing members of another culture, lectures |
| Godkin, 2003 | CCT | Pre-prof | GC, SC | A/PI, AA, H | NS | Culture immersion |
| Studies on nurses | ||||||
| Frank-Stromborg, 1987 | Pre/post | Prof | SC | AA | One day session held once only | Demonstration/role modeling, give-and-take (group), lectures |
| Frisch, 1990 | CCT | Pre-prof | GC, SC | H | Six weeks full- fourth dimension | Civilisation immersion |
| Alpers, 1996 | CCT | Pre-prof | GC, SC | A/PI, AA, H | NS | Home visits |
| Williamson, 1996 | Pre/post | Pre-prof | GC | NS | Sessions held weekly | Sound/visual, clinical experiences, civilization immersion, discussion (grouping), interviewing members of another civilization |
| Flavin, 1997 | Pre/post | Prof | D-P, SC | A/PI | < 2-hour sessions held weekly for 3 weeks | Audio/visual, case scenarios, discussion (group) |
| St Clair, 1999 | CCT | Pre-prof | GC, D-P | AA | 2–3 weeks full time | Culture immersion |
| Underwood, 1999 | Pre/mail service | Prof | SC | AA | NS | Case scenarios, demonstration/role modeling, lectures, outreach with national prevention organization |
| Jeffreys, 1999 | Pre/postal service | Pre-prof | GC, SC | NS | NS | Clinical experiences, discussion (grouping), lectures, written assignments |
| Napholz, 1999 | CCT | Pre-prof | GC, L, SC | AA | Three ii-hr sessions | Clinical experiences |
| Inglis, 2000 | Pre/post (external control) | Pre-prof | D-P, SC | A/PI | Iii weeks full fourth dimension | Lectures, visits to local hospitals and health centers, field trip |
| Lasch, 2000 | RCT | Prof | SC | NS | One 1-mean solar day sessions held once simply | Clinical experiences, give-and-take (group), lectures |
| Scisney-Matlock, 2000 | CCT | Pre-prof | GC | NS | NS | Lectures, web pages, written and exact presentations |
| Smith, 2001 | CCT | Prof | GC, SC | NS | 1 session held once only | Case scenarios, demonstration/role modeling, lectures, simulations |
| Studies on mixed groups of healthcare providers | ||||||
| Erkel, 1995 | Pre/post | Pre-prof | SC | AA | five weeks total time | Audio/visual, case scenarios, clinical experiences, culture immersion |
| Gany, 1996 | Pre/post | Prof | L, SC | A/PI, AA, H | 4 sessions | Discussion (group), personal experiences |
| Gallagher Thompson, 2000 | Pre/post | Prof | D-P, SC, A | H | I session held once only | Audio/visual, word (group), lectures |
| Way, 2002 | Pre/post | Prof | GC | NS | One sessions held once merely | NS |
| Studies on other types of healthcare providers | ||||||
| Stumphauzer, 1983 | Pre/post | Prof | GC, A | A/PI | Two hour sessions held weekly for x weeks | Case scenarios, give-and-take (group) |
| Wade, 1991 | RCT | Prof | SC | AA | 4 hours total | Discussion (group) |
| Hansen, 2002 | Post merely (external control) | Pre-prof | GC, D-P, 50, SC | NS | 2 1-day sessions | Discussion (group), writing cultural autobiography |
Outcome of Cultural Competence Training on Wellness Care Providers
Figure 2 shows the number of studies showing beneficial, partial/mixed, harmful, or no effects by type of event. A summary of outcomes of these studies is provided in Table three and detailed in Appendix A.
Number of studies showing benign, partial/mixed, harmful, or no result reported by outcome.
TABLE 3
Summary of Results of 34 Studies Evaluating Interventions to Better Cultural Competence Grooming of Health Professionals*
| Provider Outcomes | Patient Outcomes | ||||||
|---|---|---|---|---|---|---|---|
| Evaluation Methods | Knowledge | Attitudes | Skills | Satisfaction | Patient Adherence | Health Status | |
| Physicians | |||||||
| Mao, 1988 | Ratings, cocky | + | + + | ||||
| Copeman, 1989 | Self, test | ? | +/? | ||||
| Rubenstein, 1992 | Ratings, exam | + +/+ + | |||||
| Nora, 1994 | Interview, ratings, exam | ++ | + | + | |||
| Culhane-Pera, 1997 | Interview, observer, ratings, cocky | ++ | +/+ | + +/+ + | |||
| Farnill, 1997 | Patient, self, video/ audiotape | + +/+ + | |||||
| Haq, 2000 | Essays, ratings, self, open-ended questions | + +/+ | + + | ||||
| Dogra, 2001 | Cocky, exam | 0/? | |||||
| Godkin, 2001 | Cocky, test | ++ | ++ | ||||
| Mazor, 2002 | Functioning audits, patient, self | + | + +/? | + +/++/++/++ | |||
| Tang, 2002 | Cocky | + +/++/+ + | |||||
| Beagan, 2003 | Interviews, questionnaires | 0/0/0 | |||||
| Crandall, 2003 | Exam; MAQ | ++ | ++ | ++ | |||
| Godkin, 2003 | Self | + +/?/+ + | |||||
| Nurses | |||||||
| Frank-Stromborg, 1987 | CAI, PAS, activities survey | + +/+ + | |||||
| Frisch, 1990 | Exam, MER | + +/0/ + | |||||
| Alpers, 1996 | Self, CSES | +/− | |||||
| Williamson, 1996 | Interview, self, test, CSES | ++ | ++ | ++ | |||
| Flavin, 1997 | Essays, ratings, test | 0 | |||||
| Jeffreys, 1999 | Cocky, TCSET | ++ | ++ | ++ | |||
| Napholz, 1999 | Cocky, exam, ECSA | + | |||||
| St. Clair, 1999 | Essays, self, periodical, field notes, CSES | + +/++/ + | |||||
| Underwood, 1999 | Ratings, self | + | +/+ | + | |||
| Inglis, 2000 | Test | ++ | |||||
| Lasch, 2000 | Exam | ++ | ++ | ||||
| Scisney-Matlock, 2000 | Self, MLSS | + +/+ + | |||||
| Smith, 2001 | Cocky, exam, CSES | ++ | ++ | ||||
| Mixed healthcare provider groups | |||||||
| Erkel, 1995 | Ratings, self | + | +/+/+ | ||||
| Gany, 1996 | Exam | ++ | ++ | ||||
| Gallagher Thompson, 2000 | Cocky, test | + +/+ + | ++ | ||||
| Way, 2002 | Ratings, patient, cocky | + | +/+ + | ++ | |||
| Other healthcare providers | |||||||
| Strumphauzer, 1983 | Observer, ratings, examination | ++ | ++ | ||||
| Wade, 1991 | Patient, B/50 RI, CES, CRF | ++ | ++ | ||||
| Hansen, 2002 | exam | + + | |||||
Appendix
Detailed Results of 34 Studies Evaluating Cultural Competence Training of Health Professionals
| Study | Outcomes |
|---|---|
| Md | |
| Beagan, 2003 | There were no differences in the percent of students who idea various characteristics of patients (for case advent, English ability, social course, race, gender, culture) afflicted their treatments. |
| In that location were no differences in the percent of students who thought physicians' social and cultural characteristics affected their medical practice. | |
| In that location were no differences in the percent of students who thought their ain social and cultural factors affected their medical school experience. | |
| Copeman, 1989 | A two-detail test of knowledge showed meaning improvement on ane item measuring noesis of cardiovascular disease but no comeback on the detail measuring mental illness amidst Aboriginals. |
| After the intervention, just 20% felt "quite competent" to interview a not-English speaking patient through an interpreter and 76% thought they could "probably manage". | |
| After the curriculum, medical students were less likely to agree, 1) that migrants take abroad jobs from other Australians (P < 0.01) and ii) that restrictions should be placed on the Aboriginal to protect him from his ain lack of responsibility (P < 0.05) and medical students were significantly more likely to agree 1) that the cause of Aboriginal poor health is disposition from their land (P < 0.01) and 2) that in general Aborigines are pretty much all alike (P < 0.05). | |
| Crandall, 2003 | Statistically significant improvement of the iv items of the skills sub-calibration occurred after the course (P= 0.000). |
| Statistically significant improvement on the 6 items of the noesis sub-calibration occurred after the course (P= 0.000). | |
| Statistically significant comeback of the 6 items of the attitudes sub-calibration occurred after the form (P= 0.000). | |
| Culhane-Pera, 1997 | Average scores on a iv-item attitudinal self-assessment improved from 3.93 to 4.1, though this change was not statistically significant. |
| Average scores on a six-item cocky-assessment of skills (related to incorporating cultural bug into clinical care) improved from 3.33 to 3.96 (P = 0.000). | |
| Residents self-assessments of their level of cultural competence significantly increased between initial and terminal evaluations. | |
| Although faculty's initial assessment of resident's level of cultural competence did not correlate well with resident's own cess r = 0.092), final competence level assessment did r = 0.507, P < 0.05). | |
| Average scores on a vi-particular knowledge self-assessment of general cultural issues improved from 2.87 to iii.47 (P = 0.000). | |
| Participants ranked the entire curriculum of 4.33/five for importance and 4.26/5 for quality. | |
| Dogra, 2001 | There was no statistical deviation in responses to case scenarios before and following training. |
| Afterwards the intervention, students had significantly unlike responses on 8 out of 25 attitudinal items about cultural issues (P < 0.05). | |
| Farnill, 1997 | Students reported significantly more competence on all self-cess dimensions (P < 0.001) related to interviewing patients of non-English language speaking patients. |
| Community volunteers reported positive experiences beingness interviewed past the students. | |
| Blinded psychologist rating of video showed students to be significantly more competent in interviewing a not-English-speaking patient in the postintervention video over preintervention video (P < 0.01). | |
| Godkin, 2001 | Students in the intervention group showed significant improvements in self-assessed cognition of cultural behavior, practices, and health needs on 8 out of 9 items. |
| Students in the intervention group showed significant improvements on 7 out of xx cultural competence items, and had significantly improve cultural competence attitudes than students who did not participate in the intervention. | |
| Godkin, 2003 | Compared to students who did not elect to travel internationally, students who traveled were significantly more interested in an international component in career, interested in working with underserved, recognizing need to know another linguistic communication and recognizing need to know a patient'due south financial constraints. |
| After traveling to another state, preclinical medical students were more probable (than earlier they had traveled) to report (on a scale from 1 to 5) that they had an involvement in an international component to their career (4.37 compared to 4.06, P < 0.001), that they had an interest in an international component to their career (3.97 compared to three.67, P < 0.01), that there is a need to understand cultural differences (4.43 compared to iv.xvi, P < 0.01), that there is a need to know another language (iv.51 compared to 4.15, P < 0.001), and that there was need to be an advocate for the whole community (iv.14 compared to three.91, P = 0.03). | |
| Later on traveling to some other country, medical students in their clinical years were more than probable (than before they had traveled) to report (on a scale from 1 to 5) that in that location was a need to sympathize cultural differences (4.51 compared to 4.23, P < 0.001), that they were enthusiastic near beingness a physician (4.17 compared to iii.86, P = 0.03), and that they had a sense of idealism in the role of physician (three.65 compared to 3.sixteen, P < 0.001), only were less likely to written report a need to work collaboratively with other professionals (three.93 compared to iv.19, P = 0.02) and that they had awareness of their future part as physicians (four.xiv compared to 4.35, P = 0.04). | |
| Haq, 2000 | 96% would recommend international health experiences to other students. |
| Participants experienced significant positive changes in attitude towards communication and community health issues (P < 0.03) betwixt the pre- and post-exam. | |
| 83% of participants said the experiences inverse how they would practice medicine. | |
| Participants gained significant positive improvements on each of x self-assessed clinical skills between the pre- and post-test (P = 0.001). | |
| Mao, 1988 | In 1986, 94% approved the use of student discussion leaders, 85% enjoyed the videotapes, and 49% establish the function playing exercises helpful. |
| In 1986 and 1987, 70% of students found that the workshop achieved its objectives and ten% wanted more than specific cultural information. | |
| In 1986 and 1987 a few students commented that the workshop should explore racial and gender problems in more depth. | |
| 1985 showed some "significant" improvement in making treatment choices in 3 example studies (paired t-tests). | |
| There was significant comeback on iii of 9 attitudes measured. | |
| Mazor, 2002 | Families in the postintervention flow were more likely to strongly agree that "the physician was concerned almost my child" (OR ii.i, [CI ane.0–4.2]) than families in the preintervention period. |
| Families in the postintervention period were more likely to strongly agree that "the physician listened to what I said" (OR 2.9, [CI i.iv–5.9]) than families in the preintervention period. | |
| Families in the postintervention were more than probable to strongly agree that "the physician made me feel comfy" (OR two.6, [CI 1.1–4.4]) than families in the preintervention period. | |
| Physicians used a professional person interpreter less oftentimes in the postintervention menstruum (55% versus 29%, odds ratio 0.34, [CI 0.16–0.71]). | |
| Physicians scored college on measures of data gathering without the use of an interpreter (17.2 pre-test versus 22.4 post-examination, P = 0.01). | |
| All but one of the physicians in the postintervention period expressed increased confidence in addressing various emergency section chief complaints in Spanish. | |
| Families in the postintervention flow were more than probable to strongly agree that "the md was respectful" (OR iii.0, [CI one.4–6.5]) than families in the preintervention period. | |
| Nora, 1994 | Castilian language proficiency went from 60% pre-test to 75% post-test. |
| Using the misanthropy scale (which indicates openness to those non like oneself), there were no significant differences betwixt intervention and control mail grade but in that location was a trend towards increased credence of others in the intervention group. | |
| Students reported liking the opportunity to meet Mexicans and traditional healers. | |
| Students were positive nearly their experience in Mexico; ane reported that it exceeded their expectations. In comments 6 months afterwards, 4 of the eight students who went to United mexican states described the experience as life- changing. | |
| Cultural knowledge of Hispanic wellness in the intervention grouping went from 40% precourse to 58% postcourse versus the control group 46% pre and 42% post (P = 0.007). | |
| Rubenstein, 1992 | Participants developed increased knowledge of ways physicians ignorance of patient's health behavior can adversely bear upon clinical meet (on Likert scale out of 5 points: pre-test 3.three, post-test 4.6 (P < 0.0001)). |
| The curriculum scored a mean rating of three.5 (0 = lowest; iv = highest) in usefulness. | |
| Participants developed increased knowledge about available resources to larn about non-conventional health behavior (pre-test 3.eight, mail service-exam 4.9 (P < 0.0001)). | |
| Tang, 2002 | Subsequently the intervention, the students reported increased understanding of the importance of incorporating sociocultural factors into patient care (P < 0.01). |
| Later on the intervention, the students reported significantly increased understanding of the impact of sociocultural issues on the patient-physician human relationship and on patients' health (P < 0.001). | |
| After the intervention, the students reported significantly greater understanding of the relationship amid sociocultural bug, wellness, and medicine (P < 0.001). | |
| NURSE | |
| Alpers, 1996 | Intervention group has a greater conviction/competence in providing intendance to African American and Hispanic clients. |
| Control group felt more confidence/competence in entering ethnically distinct customs, and understanding Asian folk health practices than did the group who had received form content on culturalism. | |
| Flavin, 1997 | The curriculum received good scores for design, relevancy of information, and meeting participant expectations. |
| There were no significant changes in "learning scores" regarding cognition of practices and values of 4 targeted cultures prior to and later the curriculum. | |
| Frank-Stromborg, 1987 | Activities survey reported increased customs activities in cancer prevention and early detection. |
| Scores on the Pittsburgh Attitude Survey (PAS) cocky study measuring cancer attitudes improved from the pre- test (mean = 81) to the post-exam (hateful = 82, P < 0.08). | |
| 94% rated simulated practice with models as first-class to above boilerplate, 98% rated the speakers as first-class to to a higher place boilerplate, and 78% rated the program as excellent. | |
| Scores on the Cancer Attitude Inventory (CAI) improved from pre-test (mean = 132) to the post-test (mean = 139, P < 0.001). | |
| Frisch, 1990 | 5 out of 9 students that increased their scores on the Measure of Epistemological Reflection (MER) went on exchange to United mexican states. |
| Seventy-one percent of the measured cerebral improvement seen in the senior form can be attributed to the Mexico program (P = 0.018). | |
| The United mexican states exchange students were 3.5 times equally likely to better evidence cognitive improvement as measured by the Measure of Epistemological Reflection (MER) than were students that did not participate. | |
| Inglis, 2000 | Students who participated in the intervention showed significant shifts on 8 out of 23 attitudinal items towards more than understanding of cross-cultural issues, whereas students in the control group showed no change on any items |
| Jeffreys, 1999 | Practical (interviewing) subscale score on the Transcultural Self-Efficacy Tool increased betwixt pre- and post-exam from 16 to 55% (P < 0.001). |
| Affective subscale scores on the Transcultural Cocky-Efficacy Tool increased betwixt pre- and post-test from 16 to 43% (P < 0.001). | |
| Cerebral subscale scores on the Transcultural Cocky-Efficacy Tool increased between pre- and postal service-test from two to 28% (P < 0.001). | |
| Lasch, 2000 | Nurses participating in both intervention programs (workshop only and enriched model) significantly changed hurting management attitudes (P = 0.01), and maintained this change at 1 year follow-upwards, whereas the command grouping had no change. |
| Both intervention groups (workshop merely and enriched model) significantly improved knowledge of cancer pain management over command grouping at postal service-test and follow-upwardly (P < 0.0001). | |
| Napholz, 1999 | Both groups significantly increased scores Ethnic Competency Skills Assessment (ECSA); withal, the experimental group increased much higher than the control grouping. |
| Scisney-Matlock, 2000 | Cognition of diverseness gained through course work was non statistically significant different between experimental group and control group. |
| Intervention grouping showed statistically meaning increase in activities devoted to understanding other racial/ indigenous groups. | |
| Intervention group showed statistically significant increase in cocky-reported social interactions with peers of unlike race/ethnicities. | |
| Intervention grouping showed statistically significant increase in satisfaction with relevance of course work to their own ethnicity. | |
| Smith, 2001 | Questionnaire measuring noesis of cultural diversity taken in 3 phases showed significant increases over time (P < 0.001) in the intervention group and no improvement in the command group. |
| Cultural self-efficacy scale (CSES) taken in the three phases, showed significant improvements in cocky-efficacy (P < 0.001) in the intervention group and no improvement in the control group. | |
| St Clair, 1999 | Continual growth in cultural self-efficacy scores for students in international clinical exercises (mean score iii.7) over those who remained in the US (mean score three.3) in the follow-up testing period (P = 0.007). |
| There was a statistically meaning increase in cultural self-efficacy scores on the post-examination in all students. | |
| Students developed sensitivity to being a minority through international experience. | |
| Underwood, 1999 | Since completing the program, many participants take designed and implemented a number of innovative cancer prevention programs. |
| Participants indicated more than confidence in their ability to positively influence cancer prevention behaviors in practice and community. | |
| Participants indicated that the curriculum inverse their attitudes towards nurses role in cancer prevention and early detection. | |
| Participants indicated increased knowledge of cancer prevention and early detection amongst African Americans. | |
| Williamson, 1996 | Attitudes about cultural patterns. Showed sustained improvements in African Americans [begin 2.77 (0.66), middle 3.31 (0.72), terminate 3.61 (0.65)], Hispanics [begin 2.58 (0.70), middle 3.31 (0.70), cease 3.69 (0.71)], and SE Asians [begin two.28 (0.69), middle 3.64 (0.69), stop three.35 (0.77)] (P < 0.001). |
| Students improved in transcultural skills (brainstorm 3.29 (SD ± 0.69), eye three.64 (SD ± 0.69), end iii.96 (SD ± 0.66) (P < 0.001)). | |
| Participants improved their cognition of cultural concepts (beginning 2.92 (± 0.74), middle 3.49 (± 0.seventy), stop three.68 (± 0.66) (P < 0.001)). | |
| OTHER PROVIDERS/MIXED GROUPS | |
| Gallagher Thompson, 2000 | Statistically meaning increased referrals of Hispanic Alzheimer patients and/or families to the appropriate specialized services most Alzheimer affliction (P < 0.005). |
| Statistically significant increase in participants knowledge of Hispanic beliefs virtually Alzheimer disease (P < 0.05). | |
| Statistically significant increment in participants general knowledge well-nigh Alzheimer disease (P < 0.005). | |
| Gany, 1996 | At that place was a significant mental attitude shift on 12-item test in which the mean score was 33.76 on the pre-test compared to 35.68 on the postal service-test (P < 0.003). |
| At that place was a pregnant cognition shift on 21 particular scale examination about immigrant health in which students scored 15.8% correct in the preintervention catamenia compared to 18.6% correct in the postintervention period (P < 0.0001). | |
| Erkel, 1995 | Interdisciplinary team interaction, exposure to new exercise opportunities, and the community-oriented primary intendance projection were the elements of the course that were most enjoyed past students. |
| Participants gained an increased awareness to barriers to care for rural clients. | |
| Participants gained increased cognition of rural, transcultural, and interdisciplinary issues; principles of example- management, patient focused care, and community oriented master care. | |
| Grade evaluations revealed that classroom and field trips met pupil expectations. | |
| 72% of students reported that the practicum influenced them to consider practicing in a rural setting. | |
| Participants gained an appreciation for rural lifestyle. | |
| Hansen, 2002 | Those who completed the plan scored 88.iii% on knowledge test, those who did non take the program (control) scored 75.3% (P < 0.001). |
| Stumphauzer, 1983 | Trainees ability to do behavioral analysis and treatment plan increased significantly (P < 0.01) from the preintervention period to the postintervention period. |
| The grade was seen past all trainees as having added "a greater deal" or "a considerable corporeality" to their knowledge base. | |
| At that place were significant increases on a 23-item test measuring cognition of behavioral modification principles, from 38% correct on pre-test to 68% correct on post-test (P < 0.01). | |
| Wade, 1991 | Cursory civilization sensitivity training produced significant differences in client perceptions of counselors and the counseling process and was more than important than racial pairing. |
| Clients assigned to counselors in culture sensitivity grooming returned for more than follow-ups (mean ii.88 versus 1.90). | |
| Way, 2002 | After the intervention there was an increased perception among patients of seeing staff members of their ethnicity (P = 0.04) and of finding magazines/reading materials on ward that independent information of interest (P = 0.04). There was also a meaning increase in patients' reporting that staff would encounter them as individuals (P = 0.06). |
| There was a statistically significant increment in participants' perception that at that place were pictures on walls that may remind patients of family/friends (P = 0.01), and that there were magazine/reading materials that contain data in which the patient may be interested (P = 0.0001). | |
| 58% of participants increased interest in learning patient and family background, and 59% of participants increased sensitivity to cultural competence. | |
| 59% of participants increased awareness of special needs of recipients who do non speak English. | |
Provider Noesis
Most studies (17/xix) demonstrated a beneficial effect on provider knowledge. 11 of these studies tested the provider'south knowledge about general cultural concepts (such as the impact of culture on the patient–provider encounter21 or the ways in which provider ignorance tin can adversely impact patientsthirteen) whereas 7 evaluated civilization-specific noesis (such as knowledge of disease burdens across particular populations12,fourteen and traditional cultural practices24,29). One commodity did not specify. There was no obvious pattern regarding which type of knowledge was impacted more by cultural competence training. Overall, at that place is excellent evidence to suggest that cultural competence preparation impacts the knowledge of healthcare providers (evidence grade A).
Provider Attitudes
Of the 25 studies that evaluated the issue of cultural competence training on provider attitudes, 21 demonstrated a benign effect, whereas 1 study showed no effect, and 3 studies showed a partial/mixed outcome. The virtually common attitude outcome measured was cultural self-efficacy measured using the Bernal and Freeman cultural cocky-efficacy scale,27,28,37 which evaluates learner confidence in knowledge and skills related to African American, Asian, Latino, and Native-American patients. Other studies measured attitudes toward community health issues17 and interest in learning about patient and family backgrounds.40 Overall, at that place is good evidence to advise that cultural competence training impacts the attitudes of healthcare providers (show class B). Although the quantity of evidence was sufficient and the results were consistent, the quality of the body of literature did non see criteria for evidence grade A because less than 75% of studies used an objective assessment of learner attitudes.
Provider Skills
Of the xiv studies that evaluated the effect of cultural competence training on the provider skills, all demonstrated a benign effect. For case, in one written report, participants were given sixteen i-hour sessions in which they expert communication skills with community volunteers and were afterward shown to be significantly more than competent in interviewing a non-English language-speaking person as rated in videos by a blinded psychologist.xvi Other behaviors that were observed included an increase in nurses' involvement in community-based cancer pedagogy programs,32 an increase in learners' self-reported social interactions with peers of different races/ethnicity,36 and an comeback in the learners' ability to deport a behavioral analysis and treatment plan.41 Overall, in that location is good testify to propose that cultural competence training impacts the skills/behaviors of healthcare providers (evidence grade B). Although the quantity of show was sufficient and the results were consequent, the quality of the trunk of literature did non run across criteria for evidence grade A considering there was no randomized controlled trial and fewer than 75% of studies used an objective outcome assessment.
Effect of Cultural Competence Training on Patient Outcomes
Only 3 studies evaluated patient outcomes: 1 targeting physicians,20 1 targeting mental health counselors,44 and ane targeting a mixed group of providers.twoscore All 3 studies reported favorable patient satisfaction measures,20,40,44 and 1 demonstrated an improvement in adherence to follow-up among patients assigned to intervention group providers.44
With regard to the methods used to bring about such improvements in patient outcomes, 1 study trained 4 mental health counselors almost the attitudes that depression-income African American women bring to counseling (4 hours)44 and establish that, in comparison with the control group, counselors were rated more highly in the domains of expertness, trustworthiness, empathy and unconditional regard. Some other report trained 9 physicians to speak the Spanish language (20 hours)twenty and found, after the intervention, that patients were more probable to agree that the doctor was concerned, respectful, and listened. A third study implemented a country-mandated 3-day training program focused on team preparation, recipient recovery principles, clinical issues and cultural competence for all staff who take contact with recipients of inpatient mental healthcare40 and found that, later on the intervention, there were improvements in patients' sense that the staff would come across them as individuals. Overall, in that location is proficient bear witness that cultural competence training impacts patient satisfaction (show class B) and poor evidence that cultural competence training impacts patient adherence or wellness outcomes (bear witness grade D).
Outcomes Associated with Specific Features of Cultural Competence Preparation
Outcomes associated with specific features of the interventions are presented in Table 4. Both shorter- and longer-duration interventions appear effective, every bit practise both methods using experiential learning and those non using experiential learning. Interventions teaching general cultural concepts, those instruction about specific cultures, and those that teach both are all associated with positive outcomes.
Table 4
Outcomes Associated With Detail Features of the Interventions
| Outcome | |||||
|---|---|---|---|---|---|
| Intervention Feature | Provider Knowledge | Provider Attitudes | Provider Skills | Patient Satisfaction | Patient Adherence |
| Length | |||||
| ≤ viii hours | 5 beneficial, 1 no effect | 6 benign, 1 mixed effect | 3 beneficial | two beneficial | ane benign |
| > ane calendar week | 5 beneficial | 7 beneficial, 1 no effect | three benign | ||
| Content | |||||
| General concepts | 3 benign | 3 beneficial, 1 mixed effect | three beneficial | 1 beneficial | |
| Specific cultures | vi beneficial, 1 no consequence | eight beneficial, 1 mixed outcome 1 no issue | v beneficial | two beneficial | |
| General and specific | 8 beneficial | 10 beneficial | 5 beneficial | ||
| Method | |||||
| Experiential* | 10 benign, 1 mixed outcome | 12 beneficial, 2 mixed result, 1 no event | 7 beneficial | ||
| Non Experiential | 7 beneficial, 1 no effect | 9 beneficial, 1 mixed effect | 7 beneficial | 3 beneficial | i beneficial |
Costs of Cultural Competence Training
Of the 34 manufactures, there were only 4 articles that addressed the costs of cultural competence training.14,17,19,20 Three of the 4 manufactures14,17,xix described the costs of interventions that involved international travel. Two programs provided United states of america$2000 (in 2000xix and in 1995–199617) for each pupil to travel from the United States to South America, Asia, or Africa for either half dozen19 or 817 weeks. In each of these programs, the students provided the remaining costs. Some other programme estimated that an viii-twenty-four hours trip from the United states of america to United mexican states cost US$1200 full in 1994, of which the students contributed 60% on boilerplate, and scholarship assistance for the remainder was bachelor through private donations.xiv
There are limited data regarding the costs of classroom instruction or other types of educational activity. One report estimated the cost of xx total hours of Castilian language instruction for 9 physicians to be US$2000 in 2000, not including the opportunity costs for doc time (approximately 20 hours total for each physician).20 In another program, there were also 60 hours of classroom pedagogy (xx hours of Spanish language instruction and xl hours of cultural competence training focused on Hispanic populations) provided for nineteen students at an estimated local cost of US$3000 in 1994, of which each pupil contributed United states$fourscore.fourteen Finally, one program involved matching 26 students to 26 local ethnically diverse families, asked the students to visit the family 6 times, and paid each family US$400 in 1996– 2000.17 Overall, there is poor data (only one study provided comprehensive data) to make up one's mind the costs of cultural competence preparation (evidence course D).
Word
Cultural competence preparation is being reported with increasing frequency in the literature and is gaining the attention of health care administrators and educators. Many different curricular methods and content areas have been evaluated. There is excellent or expert evidence that cultural competence training impacts intermediate outcomes such equally the noesis, attitudes, and skills of health professionals. Good prove besides exists that cultural competence training impacts patient satisfaction and bereft show that training impacts patient adherence (although the one written report designed to do this demonstrated a positive impact). No studies have evaluated patient health outcomes.
It has been suggested that all cultural competence interventions should target the knowledge, attitudes, and skills of health professionals, and so measurement of these intermediate outcomes are appropriate, and results are encouraging.1 Intermediate outcomes might ultimately impact patient outcomes considering that health intendance providers who are more knowledgeable nearly their patients' backgrounds, who have more positive attitudes towards their patients, and who have the skills to communicate and employ a patient-centered approach are probable to provide better care to their patients.45 The Plant of Medicine report, Diff Treatment, suggests that the machinery involved in the link betwixt improved advice and improved patient health status may exist through improved patient satisfaction and adherence.i The same mechanism may exist operating with improved provider cultural competence, but information technology is additionally possible that culturally competent wellness professionals may actually be more good in obtaining histories and therefore in making diagnoses.
Concerns have existed virtually whether specific cultural data taught in curricula using a knowledge-based, chiselled approach might promote stereotyping of patients.1,4 Although our study found that curricula teaching about specific cultures were associated with positive outcomes in full general, one of the studies in our review demonstrated that, following an intervention that taught specific cultural information, students were more likely to believe that Aboriginal people were all akin.12 Given this finding, and other prove demonstrating that providers showroom bias and stereotyping behavior in their interactions with indigenous minority patients,46,47 this phenomenon should be evaluated with further studies. Only 2 of the 34 studies in our review included mention of concepts of racism, bias or discrimination in their content, which, in theory, might reduce the likelihood of this upshot. Some other strategy to avoid stereotyping, recommended by medical educators, is a patient-centered approach that emphasizes general concepts of culture in addition to providing specific cultural data.iv
Although this systematic review adamant that cultural competence preparation impacts provider knowledge, attitudes and skills, it is difficult to conclude from the literature which types of training interventions are most effective on which types of outcomes due to the heterogeneity and intermingling of curricular content and methods. At that place were no 2 studies that evaluated the exact aforementioned educational experience, and there were no studies that compared different types of grooming methods or content. Withal, almost all studies reported a positive upshot, suggesting that employing whatsoever intervention may be effective. In particular, our review suggests that both longer and shorter duration interventions, experiential as well as nonexperiential, and curricula focusing on general concepts of civilization and specific cultural information (alone and separately) are all associated with positive outcomes. This should exist of smashing interest to medical educators and policy makers, and suggests information technology might be reasonable to compare interventions of varying length and content in a randomized controlled fashion.
We found that there was piffling uniformity across studies in measurement of outcomes (even inside upshot categories), making it difficult to determine which specific types of knowledge, attitudes, or skills are impacted by cultural competence training. For example, some studies tested students on specific cultural information whereas other studies tested students on full general cultural concepts, merely no two studies reported using the same noesis assessment tool. Although several studies used standardized measures of cultural self-efficacy, a wide range of attitudes was measured past the studies. Finally, there was also variation in skills measured, which ranged from developing a behavioral treatment plan to socializing with peers across race/ethnicity and would likely have very unlike and possibly uncertain effects on clinical care. Futurity studies ought to link specific provider skills (for example, communication skills to address cultural barriers to adherence) to the relevant patient outcomes of involvement (for example, adherence to recommended treatments).
Organizations and providers may accept limited resources to bear educational programs to improve cultural competence. There is insufficient bear witness to determine the cost of cultural competence training because but 5 articles included data on costs and because the cost information contained in these 5 articles was too limited to allow for a comprehensive approximate. However, one of the studies that was able to demonstrate an comeback in patient satisfaction also included information about cost, and so perhaps the best evidence is found in that report, where it was estimated to cost $2000 (not including the price of physician time) to train ix emergency department physicians in the Spanish language.twenty It is also worth noting that both shorter and longer interventions were constructive, suggesting that future studies should evaluate the added benefit of additional investments of time.
The limitations of the existing literature provide a template for future research on cultural competence. First, further enquiry would be aided greatly by a compatible conceptual model for provider cultural competence and by a standardized, validated instrument to mensurate cultural competence. This would allow for comparisons between studies in the time to come. Second, given the heterogeneity of curricular interventions, it would exist helpful to take studies that compare interventions varied by either curricular content or training methods (ie, those that focused on general versus specific concepts of culture, those that employ experiential learning compared with classrooms, and and so on). Third, and probably most important, studies should endeavour to measure patient outcomes. Finally, researchers should include data about the resources and costs of training, so that those who wish to employ interventions to improve the quality of intendance for racial/ethnic minorities know the investment that must be made in cultural competence to achieve a given outcome.
The results of our written report should be interpreted with several limitations in mind. Outset, we were merely able to review published studies. Therefore, there is the possibility of publication bias; that is, published studies are more than likely to show a positive effect of cultural competence training than unpublished piece of work. Indeed, most studies examining knowledge, attitudes, and skills were positive studies. Second, we limited our review to articles published in English and to those articles published afterwards 1980. Nevertheless, we believed these studies would be most relevant given changes in population demographics and the paradigms of medical pedagogy. Third, we developed our own criteria to grade the forcefulness of the prove; however in that location are no previously used systems for grading testify that are designed for educational interventions. We are explicit almost the method, though, so others could utilize different standards if they choose. Finally, our review focused on interventions aimed at the education of health care providers, rather than on all possible organizational strategies to provide culturally and linguistically appropriate services, equally other recent reviews accept focused more than specifically on organizational cultural competence.48
Decision
In decision, cultural competence training shows promise every bit a strategy for improving wellness intendance professionals' knowledge, attitudes, and skills and patients' ratings of care. We believe that interventions that focus on the avoidance of bias, general concepts of culture, and patient-centeredness are promising strategies that should be prioritized for farther study. Farther inquiry should also focus on the evolution of standard instruments to measure cultural competence. Studies evaluating the impact of cultural competence training should compare different methods of teaching cultural competence, employ objective and standardized evaluation methods and measure patient outcomes including patient adherence, health status and equity of services across racial and indigenous groups.
ACKNOWLEDGMENTS
This commodity is based on research conducted by the Johns Hopkins Evidence-based Do Center under contract to the Bureau for Healthcare Research and Quality (Contract No. 290-02-0018), Rockville, MD. The authors of this article are responsible for its contents, including whatsoever clinical or handling recommendations. No statement in this article should exist construed as an official position of the Bureau for Healthcare Research and Quality or of the The states Department of Wellness and Human Services.
REFERENCES
1. Commission on Understanding and Eliminating Racial and Indigenous Disparities in Wellness Care. Unequal Treatment: Against Racial and Ethnic Disparities in Care. Washington, DC: The National Academies Press; 2002. [PMC free article] [PubMed] [Google Scholar]
ii. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57 Suppl one:181–217. [PMC free article] [PubMed] [Google Scholar]
3. Cooper LA, Roter DL. Patient-provider communication: The effect of race and ethnicity on process and outcomes of healthcare. In: Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2002. pp. 552–593. [Google Scholar]
4. Betancourt JR, Green AR, Carrillo JE, et al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Wellness Rep. 2003;118:293–302. [PMC free article] [PubMed] [Google Scholar]
5. Office of Minority Health DoHaHS. National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care. Federal Annals. 2002;65:247. [Google Scholar]
7. Beach MC, Cooper LA, Robison KA, et al. Strategies for Improving Minority Healthcare Quality. Rockville, Dr.: Bureau for Healthcare Research and Quality; 2004. Bear witness Report/Engineering science Assessment No. 90. AHRQ Publication No. 04-E008-02. [Google Scholar]
8. Peña DE, Muñoz C, Grumbach One thousand. Cross-cultural education in U.S medical schools: development of an assessment tool. Acad Med. 2003;78:615–622. [PubMed] [Google Scholar]
nine. Sackett DL, Haynes RB, Guyatt GH, et al. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Boston/Toronto/London: Little, Chocolate-brown, and Company; 1991. [Google Scholar]
10. W S, Rex V, Carey TS, et al. Systems to rate the forcefulness of scientific show. Evidence Study/Technology Assessment No. 47. Rockville, MD: Agency of Wellness Intendance Policy and Research; 2002. AHRQ Publication No. 02-E016. [Google Scholar]
xi. Mao C, Bullock CS, Harway EC, Khalsa SK. A workshop on ethnic and cultural awareness for 2nd-yr students. J Med Educ. 1988;63:624–628. [PubMed] [Google Scholar]
12. Copeman RC. Medical students, Aborigines and migrants: evaluation of a teaching programme. Med J Aust. 1989;150:84–87. [PubMed] [Google Scholar]
13. Rubenstein HL, O'Connor BB, Nieman LZ, et al. Introducing students to the office of folk and popular health belief-systems in patient care. Acad Med. 1992;67:566–568. [PubMed] [Google Scholar]
14. Nora LM, Daugherty SR, Mattis-Peterson A, et al. Improving cross-cultural skills of medical students through medical schoolhouse-customs partnerships. West J Med. 1994;161:144–147. [PMC free article] [PubMed] [Google Scholar]
15. Culhane-Pera KA, Reif C, Egli E, et al. A curriculum for multicultural didactics in family medicine. Fam Med. 1997;29:719–723. [PubMed] [Google Scholar]
16. Farnill D, Todisco J, Hayes SC, et al. Videotaped interviewing of non-English speakers: grooming for medical students with volunteer clients. Med Educ. 1997;31:87–93. [PubMed] [Google Scholar]
17. Haq C, Rothenberg D, Gjerde C, et al. New globe views: preparing physicians in training for global health piece of work. Fam Med. 2000;32:566–572. [PubMed] [Google Scholar]
18. Dogra N. The evolution and evaluation of a program to teach cultural diverseness to medical undergraduate students. Med Educ. 2001;35:232–241. [PubMed] [Google Scholar]
19. Godkin MA, Savageau JA. The result of a global multiculturalism rails on cultural competence of preclinical medical students. Fam Med. 2001;33:178–186. [PubMed] [Google Scholar]
20. Mazor SS, Hampers LC, Chande VT, et al. Teaching Spanish to pediatric emergency physicians: furnishings on patient satisfaction. Arch Pediatr Adolesc Med. 2002;156:693–695. [PubMed] [Google Scholar]
21. Tang TS, Fantone JC, Bozynski ME, et al. Implementation and evaluation of an undergraduate Sociocultural Medicine Programme. Acad Med. 2002;77:578–585. [PubMed] [Google Scholar]
22. Beagan BL. Educational activity social and cultural sensation to medical students: "it's all very nice to talk nearly it in theory, just ultimately information technology makes no divergence" Acad Med. 2003;78:605–614. [PubMed] [Google Scholar]
23. Crandall SJ, George G, Marion GS, et al. Applying theory to the blueprint of cultural competency training for medical students: a case study. Acad Med. 2003;78:588–594. [PubMed] [Google Scholar]
24. Godkin M, Savageau J. The effect of medical students' international experiences on attitudes toward serving underserved multicultural populations. Fam Med. 2003;35:273–278. [PubMed] [Google Scholar]
25. Frank-Stromborg M, Johnson J, McCorkle R. A program model for nurses involved with cancer education of black Americans. J Cancer Educ. 1987;2:145–151. [PubMed] [Google Scholar]
26. Frisch NC. An international nursing pupil substitution program: an educational feel that enhanced pupil cognitive development. J Nurs Educ. 1990;29:ten–12. [PubMed] [Google Scholar]
27. Alpers RR, Zoucha R. Comparison of cultural competence and cultural confidence of senior nursing students in a private southern university. J Cult Defined. 1996;3:9–15. [PubMed] [Google Scholar]
28. Williamson E, Stecchi JM, Allen BB, et al. Multiethnic experiences enhance nursing students' learning. J Community Health Nurs. 1996;13:73–81. [PubMed] [Google Scholar]
29. Flavin C. Cantankerous-cultural training for nurses: a research-based education projection. Am J Hosp Palliat Care. 1997;14:121–126. [PubMed] [Google Scholar]
thirty. Jeffreys MR, Smodlaka I. Steps of the instrument design procedure. An illustrative approach for nurse educators. Nurse Educ. 1996;21:47–52. [PubMed] [Google Scholar]
31. Napholz L. A comparison of self-reported cultural competency skills among 2 groups of nursing students: implications for nursing education. J Nurs Educ. 1999;38:81–83. [PubMed] [Google Scholar]
32. Underwood SM. Development of a cancer prevention and early detection program for nurses working with African Americans. J Contin Educ Nurs. 1999;30:30–36. [PubMed] [Google Scholar]
33. St Clair A, McKenry L. Preparing culturally competent practitioners. J Nurs Educ. 1999;38:228–234. [PubMed] [Google Scholar]
34. Inglis A, Rolls C, Kristy S. The impact on attitudes towards cultural difference of participation in a health focused study away program. Contemp Nurse. 2000;9:246–255. [PubMed] [Google Scholar]
35. Lasch KE, Wilkes G, Lee J, Blanchard R. Is easily-on experience more than effective than didactic workshops in postgraduate cancer pain education? J Cancer Educ. 2000;15:218–222. [PubMed] [Google Scholar]
36. Scisney-Matlock M. Systematic methods to enhance diversity knowledge gained: a proposed path to professional richness. J Cult Divers. 2000;7:41–47. [PubMed] [Google Scholar]
37. Smith LS. Evaluation of an educational intervention to increase cultural competence among registered nurses. J Cult Divers. 2001;8:50–63. [PubMed] [Google Scholar]
38. Erkel EA, Nivens AS, Kennedy DE. Intensive immersion of nursing students in rural interdisciplinary intendance. J Nurs Educ. 1995;34:359–365. [PubMed] [Google Scholar]
39. Gany F, de Bocanegra HT. Maternal-kid immigrant health training: irresolute knowledge and attitudes to improve health intendance delivery. Patient Educ Couns. 1996;27:23–31. [PubMed] [Google Scholar]
40. Way BB, Rock B, Schwager K, Wagoner D, Bassman R. Effectiveness of the New York State Part of Mental Wellness Core Curriculum: direct intendance staff training. Psychiatr Rehabil J. 2002;25:398–402. [PubMed] [Google Scholar]
41. Stumphauzer JS, Davis LC. Preparation community-based, Asian-American mental health personnel in behavior modification. J Community Psychol. 1983;xi:253–258. [PubMed] [Google Scholar]
42. Hansen ND. Teaching cultural sensitivity in psychological cess: a modular approach used in a distance education plan. J Pers Assess. 2002;79:200–206. [PubMed] [Google Scholar]
43. Gallagher Thompson D, Haynie D, Takagi KA, et al. Impact of an Alzheimer's affliction instruction program: focus on Hispanic families. Gerontol Geriatr Med. 2000;20:25–40. [Google Scholar]
44. Wade P, Berstein B. Culture sensitivity training and counselor's race: effects on black female client's perceptions and attrition. J Couns Psychol. 1991;38:9–15. [Google Scholar]
45. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423–1433. [PMC free commodity] [PubMed] [Google Scholar]
46. Schulman KA, Berlin JA, Harless Due west, et al. The effect of race and sex activity on physicians' recommendations for cardiac catheterization. Northward Engl J Med. 1999;340:618–626. [PubMed] [Google Scholar]
47. van Ryn M, Burke J. The issue of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med. 2000;l:813–828. [PubMed] [Google Scholar]
48. Anderson LM, Scrimshaw SC, Fullilove MT, et al. Culturally competent healthcare systems. A systematic review. Am J Prev Med. 2003;24(3 Suppl):68–79. [PubMed] [Google Scholar]
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3137284/
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