RCCHC Services and Products
Cross Currents Newsletter and RCCHC Resources Manual
Linguistic and Cultural Competence Standards Project
National Conference on Cultural Competence
Kaiser Forum on Addressing Language Barriers to Health Care

Developing a Research Agenda for Cultural Competence in Health Care:
Cultural Competence Training
Draft research agenda--version 1.0

Resources for Cross Cultural Health Care
and the U.S. Department of Health and Human Services
Office of Minority Health and the Agency for Healthcare Research and Quality

We invite public input on our draft research agendas. Please read the following document and send your comments to rcchc@aol.com. We are especially looking for recommendations for additional research questions and methodological/policy considerations. We are also seeking additional bibliographic references for the literature review abstracts. Comments received by December 10 will be incorporated into the final report–comments will also be posted online.

Definition

Cultural competence training broadly describes a vast array of educational activities aimed at enhancing the capacity of the service delivery system to meet the needs of different racial and ethnic populations. The literature suggests that cultural competence training can include educational activities aimed at increasing sensitivity and awareness; the provision of multicultural health and demographic information on service area populations; skills building in bicultural and bilingual interviewing and patient assessment; enhancing the use of race or ethnic-specific epidemiological data in diagnosis and treatment; and increasing cultural knowledge and understanding. It is believed that the knowledge gained through training will enable providers and institutions to work more effectively in cross-cultural situations by developing new approaches to communication, patient care, and services planning that are based on culture and language.  

Synthesis Of Findings From Current Literature

Descriptive studies

The literature findings can be separated into two distinct groupings. The majority of the current literature encompasses descriptive studies of cultural competency training, delivery approaches and techniques; arguments for using training as a means to eliminate disparities and surveys of the prevalence of training in different educational settings. The content of training described in these studies varied widely and it is difficult to discern whether different approaches or content resulted in better post-training outcomes, or whether these variations have a subsequent impact on behavior. Findings suggest that additional research is needed to determine whether the standardization of cultural competence education is appropriate and effective, how established goals and objectives can be empirically measured, and best approaches for attaining identified outcomes

Impact of training on participants

The remaining literature attempts to answer questions related to the impact of training on trainees and subsequent outcomes. In an attempt to quantify the impact of training on trainees, studies examined levels of cultural knowledge, attitudes, awareness, satisfaction and communication skills. Studies that empirically measured the impact of training found that self-assessments indicated significant increases in levels of cultural knowledge, attitudes and awareness in both single and comparative groups. However, non-subjective measures found that knowledge improved in some areas but not others, modest improvements in some attitudes, and few improvements in communication skills. Studies that examined the impact of training on sensitivity generated inconclusive and often contradictory results.

Several comparative studies attempted to determine the impact and effectiveness of variations in training presentation and content. These studies reported different levels of effectiveness. However, others found no difference when measured empirically.

Impact of training on care

Very few studies examined the impact of training on patient behavior change or health outcomes. There is a need to define which are the most desirable outcomes from the patient-provider relationship, and which are the most reliable indicators of positive improvements that could result from training. One study attempted to measure the impact of training from the perspective of the patient using both subjective and objective measurements of satisfaction and follow-up compliance. Research activities currently underway by Thom et al (see literature matrix) will attempt to assess the impact of cultural competence training on measures of competency, patient trust and satisfaction, adherence to treatment and subsequent health outcomes.  

Literature Search Terms

Cultural competence, cultural competency education, cultural education, diversity training, cultural sensitivity training, ethnic specific information, ethnic specific training, culture, cross cultural medicine, cultural immersion, foreign physician placement.

Key Research Questions

The scientific base supporting the use of cultural competency education and training makes the assumption that positive impacts on trainees will result in behavioral changes that will facilitate the delivery of culturally competent care. It is also assumed that these changes will eventually translate into improvements in health outcomes. Clearly there is a need to examine and validate each of these assumptions, including an examination of the types of education that have the most effective impact on subsequent outcomes. Research questions for consideration can be separated into similar categories.

A. Research that attempts to further define/understand the intervention itself

Content Of Training

What behaviors, attitudes, and/or clinical communication techniques can impact the delivery of care with ethnic populations, and what kind of training affects these traits?

1. Are different educational delivery techniques significantly more effective than didactic training? Are some more effective in changing behavior than others? Can education on cultural issues translate into changes in behavior and service delivery in the absence of skills training? What is the impact of format, content, and length of training? How do we isolate the impact of training from inherent skill, personality, and other intangibles? What do clients want out of an encounter and does this vary by ethnicity?
2. How should training be tailored to different target groups (e.g., management, clinical, support staff; or individuals in practice v. those in training)? What competencies and basic skills need to be incorporated into training curricula and education to address the needs of individual disciplines and/or education settings? How much of training can generic in content and approach v. training that focuses on specific cultures or ethnic groups? What are the contingencies for monitoring and revising education when the demographics of an institution’s service population change?

B. Research that examines specific outcomes related to the intervention

Impact Of Training On Trainees:

1. What degree of knowledge or awareness translates into action? Can variations in behavior be attributed to a certain level of knowledge, awareness or sensitivity and are changes sustainable? Which methods are most reliable for assessing impact of training on knowledge, attitudes, behaviors, and skills?
2. Do the effects of training vary among different target groups (e.g. students, practicing clinicians, planners, various disciplines, etc.)? What is the potential for reinforcing negative perceptions and attitudes as a result of different training formats? Are there outcome differences associated with individuals who have a prior interest in cultural issues, or who have very diverse client profiles?

Impact Of Training On Behavioral Change And Health Outcomes:

How do we measure and evaluate the impact of training on outcomes? This question aims to address issues related to the development of methodologies that can evaluate the impact of training on outcomes and assist in the identification of models that yield the most positive impact. What are the most desirable outcomes? Possibilities include adherence to treatment recommendations, keeping recommended follow-up visits, appropriate utilization of services, patient satisfaction, diagnostic success, elicitation of key clinical information? Should improvements beyond intermediary outcomes be expected?

Methodological Considerations Impacting Future Research

Variations in studies highlight a fundamental problem with the myriad definitions of training: since there is no universal standard for training, nor a standard definition of cultural competence, there can be no comparability among existing studies of the "cultural competence" of subjects participating in different training programs. This further supports the need for a more thorough examination of the types of competencies needed in various disciplines and educational settings. Methodological problems associated with assessing the impact of cultural competence training include relying on subjective self-assessment of cultural competence, knowledge and awareness. Some use independently developed assessment tools, others use tools designed for use with training curricula. Many rely on knowledge-based tests rather than observations of behavior and subsequent change. This may present a false sense of security on the part of individuals who are able to absorb facts and theorize easily, but have difficulty putting them into practice, while falsely validating specific training modules. Additionally, this methodology is predisposed to bias where often, respondents have a tendency not to objectively to questions relating to social norms. Individuals are likely to give a "socially acceptable" response whether or not this is really an honest reply or attempt to answer a question correctly as possible, so their competency level will rate high. Future research should consider examining the impact of training on providers and their clients. Many of the studies examining training were aimed at students, not providers, and therefore changes in behavior or service delivery could not be assessed.

literature review abstracts >

essentials | models and practices | policy | legal issues | networking | table of contents | contact us | who we are

Copyright © 2001, DiversityRx; www.diversityRx.org, Last update: Tuesday, March 25, 2003

 Diversity Rx is sponsored by: