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The Third National
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October
2 - 4, 2002, Chicago, IL |
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Preconference | Wed., October 2nd | Th., October 3rd | Fr., October 4th | | ||||||||||
Session E-3: Outcomes research on cultural competence: setting the agendaDoes Cultural Competence Work? Setting the agenda for linking interventions to outcomesHealth care organizations have many reasons for adopting cultural competence programs and interventions: consumer demand, mission orientation, reducing access barriers, etc. But they all have the same question: does cultural competence really work? Which approaches are the most effective? Can they improve organizational efficiency? Do any of them improve patient outcomes? This presentation will review the current state of health services research on cultural competence and outcomes, and report what the evidence base says, and what further research is needed to convincingly make the case for cultural competence programs. It will review some of the opportunities and barriers researchers face in designing research studies on cultural competence and getting the results of their research published in respected journals. The report this presentation is based on is a companion piece to the USDHHS Office of Minority Health and Agency for Healthcare Research and Quality-funded project, Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda. The National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care were published by HHS in the Federal Register in December 2000, and the research agenda described in this presentation will be released by OMH and AHRQ this month and be available online (http://www.diversityRx.org). Julia Puebla Fortier has more than 14 years experience working in and writing about health care and specializes in linguistic and cultural competence in health care and Federal health policy analysis. As founder and director of Resources for Cross Cultural Health Care, she manages an international alliance of individuals and organizations in ethnic communities and health care organized to offer information and technical assistance on linguistic and cultural competence in health care. Activities include program design, policy development and analysis, research, and community advocacy. RCCHC is a coproducer of the national conference series, "Quality Health Care for Culturally Diverse Populations. Ms. Fortier has developed and manages the DiversityRx website--a comprehensive clearinghouse of information on model programs, policies and legal issues related to cross cultural health--and its listserv of over 400 participants. She was the principal investigator and author of the HHS-sponsored The National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care, and an accompanying research agenda, and co-author of model contract language on cultural competence for managed care organizations.
The Rewards and Pitfalls of Conducting Research on Language Barriers to Access to HealthcareThe conversation between physician and patient has long been recognized to be of diagnostic import and therapeutic benefit. Unfortunately many patients in the United States cannot benefit from this fundamental interaction because of language barriers. A large and growing body of evidence has documented how language barriers impact on the health and health care of persons with limited English proficiency. Less research has been done to investigate the impact of efforts of overcoming language barriers in health care. In this presentation I will:
Dr. Jacobs is a Clinician-researcher and Assistant Professor of Medicine at Cook County Hospital and Rush Medical College. She attended medical school at University of California at San Francisco, trained as a general internist at Brigham and Women’s Hospital in Boston, and completed a Robert Wood Johnson Clinical Scholars Fellowship at the University of Chicago. Her research interests include access to, and cultural specificity of, medical care delivered to minority patients. She has conducted research on the impact of interpreter services on delivery and cost of care to patients with limited English-proficiency and recently received a grant from the NCI to study the relationship between general trust in physicians and health care institutions and cancer screening among African-American women. In addition, she cares for patients at a neighborhood health center, works with other investigators to design culturally specific research, and teaches residents and faculty about practicing culturally sensitive medicine and the use of race and ethnicity variables in research.
Assessment of Clinical Outcomes Associated with Culturally Competent Clinical CareCultural competency training is being widely promoted as a means to improve the quality of health care for ethnic minorities. While regulations and legislation increasingly requires cultural competency training and demonstration of cultural competence, relatively little work has been done on developing a valid and reliable measure of cultural competence or on investigating the relationship between cultural competence and the quality of health care. Our two-year study, funded, by the California Endowment, was designed to refine, pilot and validate a measure of cultural competence. We also evaluated the impact of a physician training program and of feedback of the results of patient surveys to the physicians. For the current study we used a measure of cultural competence based on a set of surveys (Client, Provider and Administrator versions) developed by Dr. Miguel Tirado (Co-Principal Investigator on the study). We adapted the client and provider surveys, which provide information on physicians behaviors thought to reflect cultural competence. The Patient (client) survey was translated into Spanish and piloted with 2 focus groups of Spanish-speaking, limited English, patients, and modified based on these focus groups. We then created consistent English, Spanish and Chinese versions of the Patient Survey and a consistent Physician (provider) Survey (English only). We also developed and provided a physician training program based on the principals of cultural competence included in our measure. This program was implemented with physicians at 2 of the 4 sites. Physicians also received personal feedback of their aggregate patient ratings of their cultural competence. As of September 1, 2002, we have enrolled over 400 patients from over 40 physicians in 4 practice settings and followed them for up to 18 months. Initial analyses have shown our 13-item measure of cultural competence to have two distinct dimensions, corresponding to "asking about beliefs and practices" and "information sharing." The scale had good internal reliability with a Cronbach’s alpha=.89 and item to scale correlations of .48 to .74. Constructed validity was supported the expected correlation between the cultural competency scale and patients trust (r=.41) and satisfaction (r=.59). Additional analyses are pending. The major challenge we faced was recruitment of non-English-speaking and limited English-speaking patients. For this group, we relied more on recruitment via phone calls and, when necessary, telephone administered surveys in their language, rather than on direct mailing of surveys. We also offered payments for each survey completed. Once patients were enrolled, however, we had a relatively good follow-up rate — between 80 and 90% at one year. Another challenged face was how to provide training to a group of busy physicians who were not self-selected for a strong interest in cultural competency. We used 3 training formats: an all day session, a half-day session and 3 noon-hour sessions. The half-day session appeared to strike the best balance between depth and convenience. From our experience, we conclude that it is possible to enroll a relatively large number of non- and limited-English speaking patients and their physicians in a longitudinal study and follow them over time. The measure of cultural competence we used appears to have good psychometric properties. We are still analyzing the data to determine construct and predictive validity and sensitivity to change. We have also developed a training curriculum based on the principals of cultural competency reflected in our measure which was well-received by the physicians. We are awaiting completion of our data collection to analyze the impact of the training on cultural competence and outcomes of care. Finally, we successfully utilized a process to provide physicians with feedback on their cultural competence via reporting ratings by their patients. Dr. Thom is Associate Professor of Family & Community Medicine at University of California, San Francisco. He received his MD degree from the University of California at San Diego School of Medicine in 1983, and MPH and PhD degrees in epidemiology from the University of Washington School of Public Health. He is board certified in family practice and is a member of the Society for Teachers of Family Medicine and the American Academy of Family Physicians. Dr. Thom practices, teaches and does research at San Francisco General Hospital. He is a co-principal investigator, with Dr. Tirado, on a study funded by the California Endowment to develop and validate a measure of cultural competence. Dr. Thom has co-taught workshops on cultural competence to physicians.
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| As with the rest of Diversity Rx, this section
is a work in progress and we welcome information on other efforts, programs,
and reports that will expand upon the information offered here. Please
let us know if you have other examples to include here. |
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essentials | models and practices | policy | legal issues
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Diversity Rx is sponsored by: |
 The National Conference of State Legislatures |
 Resources for Cross Cultural Health Care |
 Henry J. Kaiser Family Foundation |
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