Teaching Culturally Appropriate Care: A Review of Educational Models and Methods

The disparities in health care and health outcomes between the majority population and cultural and racial minorities in the United States are a problem that likely is influenced by the lack of culturally competent care. Emergency medicine and other primary-care specialties remain on the front lines of this struggle because of the nature of their open-door practice. To provide culturally appropriate care, health care providers must recognize the factors impeding cultural awareness, seek to understand the biases and traditions in medical education potentially fueling this phenomenon, and create a health care community that is open to individuals' otherness, thus leading to better communication of ideas and information between patients and their health care providers. This article highlights the rationale for and current problems in teaching cultural competency and examines several different models implemented to teach and promote cultural competency along the continuum of emergency medicine learners. However, the literature addressing the true efficacy of such programs in leading to long-lasting change and improvement in minority patients' clinical outcomes remains insufficient.     

The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial

OBJECTIVE: We evaluated the impact of automated telephone disease management (ATDM) calls with telephone nurse follow-up as a strategy for improving outcomes such as mental health, self-efficacy, satisfaction with care, and health-related quality of life (HRQL) among low-income patients with diabetes mellitus. RESEARCH DESIGN: This was a randomized, controlled trial. SUBJECTS: Two hundred forty-eight primarily English- and Spanish-speaking adults with diabetes enrolled at the time of visits to a county health care system. INTERVENTION: In addition to usual care, intervention patients received biweekly ATDM calls with telephone follow-up by a diabetes nurse educator. Patients used the ATDM calls to report information about their health and self-care and to access self-care education. The nurse used patients' ATDM reports to allocate her time according to their needs. MEASURES: Patient-centered outcomes were measured at 12 months via telephone interview. RESULTS: Compared with patients receiving usual care, intervention patients at follow-up reported fewer symptoms of depression (P = 0.023), greater self-efficacy to conduct self-care activities (P = 0.006), and fewer days in bed because of illness (P = 0.026). Among English-speaking patients, those receiving the intervention reported greater satisfaction with their health care overall and with the technical quality of the services they received, their choice of providers and continuity of care, their communication with providers, and the quality of their health outcomes (all P <0.042). Intervention and control patients had roughly equivalent scores for established measures of anxiety, diabetes-specific HRQL, and general HRQL. CONCLUSIONS: This intervention had several positive effects on patient-centered outcomes of care but no measurable effects on anxiety or HRQL.     

Addressing cultural barriers to the successful use of insulin in Hispanics with type 2 diabetes

Hispanics experience a higher rate of diabetes than non-Hispanic whites and tend to have worse glycemic control and a greater risk of diabetes-related complications. Once oral antidiabetic agents become insufficient, insulin plays an important role in achieving glycemic goals. However, many Hispanic patients are resistant to initiating insulin therapy or hesitant to increase doses, as necessary, to control their glucose levels. Barriers to insulin therapy include socioeconomic issues (eg, cost, insurance status), language difficulties, poor health literacy, and cultural beliefs that impact the patient-provider relationship and negatively affect patients' perceptions of diabetes and insulin. Healthcare providers can help overcome these issues and improve patient-provider communication by practicing culturally competent care. Implementation of a simple titration regimen using once-daily basal insulin may enable Hispanic patients to maintain glycemic control and improve outcomes.     

The Crossroads of Culture and Health Among the Roma (Gypsies)

Purpose: To alert health care providers to commonly encountered cross-cultural impediments to optimal health care delivery for the Roma (also known as Gypsies) and to offer suggestions for avoiding culturally based problems in treating this subculture.
Organizing framework: Understanding of sociocultural bases of health-related behaviors is necessary for culturally competent and effective health care.
Methods: Review of literature and personal interviews.
Findings: Cultural factors that can affect health care delivery include: concepts of pollution, cleanliness, ideal weight, death, and views of medical procedures such as immunizations and surgery. Responsiveness of health care providers to expectations of Roma about their involvement of family and the hierarchy of age and sex also can enhance patient-provider relationships that in turn can improve compliance and satisfaction with health care regimens .
Conclusion: The Roma have some culturally distinct beliefs and behaviors related to their health and health care. Knowledge of these characteristics and accommodations to cultural differences are important in their health care.     

Cultural sensitivity in physician-patient relationships: perspectives of an ethnically diverse sample of low-income primary care patients

BACKGROUND: Health care providers and health care training institutions need more specific, relevant, and useful information for providing culturally sensitive health care. OBJECTIVE: We sought to determine what patients considered to be culturally sensitive health care. RESEARCH DESIGN AND PARTICIPANTS: We conducted 20 focus group interviews with 135 mostly low-income primary care patients from three different ethnic/cultural groups (African American, European American, and Latino American). Focus group interviews were recorded, transcribed, and analyzed into themes by two researchers using the constant comparative method. MEASURES: Participants' responses were grouped into primary and secondary themes. RESULTS: Results revealed the following universal themes of health care delivery by physicians that all three racial or ethnic groups identified as indicators of culturally sensitive health care: people skills, individualized treatment, effective communication, and technical competence. Results also revealed some ethnic group-specific themes. Other factors including physical environment characteristics (eg, culturally sensitive art, pictures, music, and reading materials) and office staff behaviors were unique indicators of culturally sensitive health care identified by African American and Latino American participants but not by European American participants. CONCLUSIONS: These findings can be incorporated into training programs for health care providers, possibly resulting in more effective health care delivery to patients from diverse cultural backgrounds. Future research is needed to evaluate the impact of incorporating patient-identified cultural sensitivity into health care delivery on important outcome measures such as patient satisfaction and treatment adherence.     

Reducing Language Bias in Nursing Education: Equipping Educators

Increasing diversity in the population and development of a stronger global focus create concern about language bias. Hesitance among patients to seek medical care and poorer patient outcomes may result from language bias among health care providers.Nurse educators can reduce the use of language bias in healthcare by increasing awareness and using inclusive language with students. The creation of educational experiences that embrace diversity and inclusion promote the delivery of culturally competent care.     

Diabetes and managed care: the Lovelace Health System's Episode of Care Program

In order to efficiently manage the care of large populations, the health of that population must be evaluated. People identified with chronic medical disorders, such as diabetes mellitus, should have their disease managed proactively in the most cost-effective manner across the continuum of care. Lovelace Health System has established an Episode of Care disease management program based on the principles of clinical practice improvement. The diabetes program is described as an example of this approach to define and monitor best practice and to decrease variation among providers. This approach optimizes the use of health care resources and improves patient outcomes.     

Economic evaluation in critical care medicine

Scarce resources are a reality in all health care systems. There is a constant challenge to maximize health benefits within the resources available. This is particularly relevant when caring for critically ill patients, given the resource-intensive technologies and medicines used and the highly specialized professionals required. Moreover, given the high acuity of illness, decision makers and health care providers in critical care units must constantly assess the value derived from therapies and resources used. Economic evaluation is the comparative analysis of alternative health care interventions in their relative costs (resource use) and effectiveness (health effects). Economic evaluations have been increasingly published in critical care journals and read by clinicians. This article illustrates how the basic principles of health economics can be applied to health care decision making through the use of economic evaluation. We demonstrate how economic evaluation can link medical outcomes, quality of life, and costs in a common index, even for therapies for different medical conditions and with different health outcomes. This article highlights the need for randomized clinical trials and economic evaluations of therapies in critical care medicine for which the effect of the therapy on health outcomes and/or costs are unknown.     

Education: nationally achievable solutions

Despite the efficacy of hypertension treatment, knowledge and compliance remain poor in Hispanic patients because of language barriers, low educational levels, and cultural differences. Yet effective physician-patient communication is crucial to patient compliance, satisfaction, and understanding of medical issues. Physicians and health care providers therefore need to develop "cultural competence" skills to achieve effective health education and good treatment outcomes in this patient population. Various strategies such as mnemonic devices can help practitioners communicate with Hispanic patients. National initiatives and research studies continue to address the provision of culturally and linguistically appropriate health care.     

Migrant farm workers and their families: Cultural patterns and delivery of care in the United States

Migrant farm workers and their families represented a critical labour pool in the planting and harvesting of agricultural products in the United States, yet their diminished health status parallel many non‐industrialized communities. The interaction of social, political, environmental and financial obstacles severely restrict access to health care among this community who often perceive insurmountable barriers to navigating the health‐care system. Through the provision of a culturally competent and sensitive assessment, community health nurses and other health providers can positively impact on health outcomes by incorporating the unique health beliefs and practices of this vulnerable population into a mutually defined plan of care.     

Community mental health services for the underserved: a culturally specific model

Underutilization of community mental health services by minorities has been an ongoing concern in the field of mental health. Many agencies are mainstream and ethnocentric in their services to culturally diverse clients, resulting in color-blind treatment approaches. During the era of civil rights, the concept of difference was used to exclude groups of individuals, families, and communities from access to resources. However, ethnicity does matter and make a difference. This article will address the need for culturally relevant services for African-American clients with the dual diagnosis of substance abuse and mental illness. The intent is to provide mental health care providers with a culturally specific model that will render culturally relevant and culturally competent services to individuals from diverse cultural backgrounds.     

Barriers to providing diabetes care in community health centers

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.     

How do rural health care providers and patients view barriers to colorectal cancer screening? Insights from appalachian kentucky

This article reports findings from a qualitative study that explored the attitudes and beliefs concerning colorectal cancer (CRC) screening among patients and health care providers in Appalachian Kentucky. Results from 5 focus groups are discussed here: 3 with primary care providers and 2 with patients. Although there are some areas of agreement, there are marked differences between the perceptions of Appalachian health care providers and participants regarding CRC screening. This article compares and contrasts those perceptions and provides suggestions for culturally competent practice and culturally relevant research to improve CRC screening in this vulnerable population.     

Mental health service needs of a Latino population: a community-based participatory research project

Community-based participatory research bridges the gap between academic researchers and the real-life issues of communities and offers promise for addressing racial and ethnic disparities in mental health care. The purpose of this community-based participatory research was to identify factors that affect access, use, and perception of mental health services by a Latino population at individual, organizational, and community levels. Individual level factors included health beliefs about mental illness and care, suspicions of providers, financial concerns, and culturally determined gender roles. Organizational factors included problems with access to care related to cost, lack of bilingual providers, and culturally competent care; and community level factors included distance between resources and the need for services to be provided in community sites. Immigration status and acculturation were identified as factors at all levels.     

Satisfaction with care among patients with diabetes in two public health care systems.

OBJECTIVES: We compared patient satisfaction among adults with diabetes treated in a Veterans Affairs (VA) health care system with the satisfaction of patients treated in a county-funded health care system. We also examined whether satisfaction differences reflected differences in the process of patient care. DESIGN: Cross-sectional telephone survey of patients recruited from outpatient clinics. SUBJECTS: Five hundred and thirty eight adults, including 310 patients from 4 VA clinics and 228 patients from 2 county clinics. MEASURES: Overall satisfaction with care and satisfaction with 6 separate dimensions of care were measured using the Employee Health Care Value Survey. RESULTS: VA patients were more satisfied than were county patients overall and with 5 of 6 dimensions of their care. These differences increased when we adjusted for patients' sociodemographic and clinical characteristics. VA patients reported more diabetes counseling and shorter waiting times to see their doctor. Each of these self-reported process measures was positively correlated with satisfaction and, when taken into account, reduced the differences in satisfaction between the two systems. However, even when we controlled both for patient characteristics and the process of care, VA patients still were more satisfied than were county patients with their care overall as well as with their access to care, communication with providers, and the quality of their health outcomes. CONCLUSIONS: In this study, VA patients with diabetes were more satisfied with their health care than were county patients. Perceived diabetes-related counseling and shorter waiting times contributed to differences between the systems in patient satisfaction but did not explain them completely.     

Effects of Cultural Sensitivity Training on Health Care Provider Attitudes and Patient Outcomes

PURPOSE: To determine the effectiveness of cultural sensitivity training on the knowledge and attitudes of health care providers, and to assess the satisfaction and health outcomes of patients from different minority groups with health care providers who received training. DESIGN: In this randomised controlled trial, 114 health care providers (nurses and homecare workers) and 133 patients (from two community agencies and one hospital) were randomly assigned to experimental (training) and control groups, and were followed for 18 months. METHODS: Providers completed the Cultural Awareness Questionnaire and the Dogmatism Scale. Patients completed the Off-Axis-Ratio (OAR) Multidimensional Measure of Functional Capacity, the Client Satisfaction Questionnaire, the Physical and Mental Health Assessment Questionnaire, and the Health and Social Services Utilization Questionnaire. A qualitative analysis was conducted to identify and analyse themes from personal journals kept by participating nurses. FINDINGS: Cultural sensitivity training resulted in increased open-mindedness and cultural awareness, improved understanding of multiculturalism, and ability to communicate with minority people. After 1 year patients of mostly European and British origin, who received care from trained providers, showed improvement in utilizing social resources and overall functional capacity without an increase in health care expenditures. CONCLUSIONS: The results of this study indicate that a cultural sensitivity training program not only improved knowledge and attitudes among health care providers, but it also yielded positive health outcomes for their patients.     

Listening to the quiet voices of Hispanic migrant children about health

There is a paucity of literature related to school-aged migrant children's perceptions of their own health. To best provide culturally competent care, more information is needed about migrant children's experiences. Focus-group methodology allowed the voices of migrant children to be heard by primary health care providers at a summer school program for children of migrant farm workers in south Georgia. Seventy-three children participated in 14 focus-group sessions. Six themes emerged from the data that were analyzed by using a qualitative software system. They are healthy behaviors, acculturation issues, environmental influences, health care actions, health behavior outcomes, and learning needs. Emerging patterns within each theme render insight about these migrant children. The findings suggest implications for pediatric nurses related to culturally competent care.     

Physician and nurse use of psychosocial strategies in diabetes care: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study

OBJECTIVE: To determine the use of psychosocial strategies by health care providers in treating patients with diabetes and the factors associated with use of these strategies. RESEARCH DESIGN AND METHODS: Cross-sectional survey of national samples of generalist and diabetes specialist physicians (n = 2,705) and nurses (n = 1,122) from the multinational study of Diabetes Attitudes, Wishes and Needs. Respondents were from 13 countries in Asia, Australia, Europe, and North America. Two psychosocial strategies were examined: provider psychosocial care, which provides psychosocial support by diabetes care providers to their own patients, and psychosocial specialist care, which refers diabetic patients to psychosocial specialists. RESULTS: Compared with physicians, nurses perceived significantly higher prevalence and severity of psychosocial problems and used psychosocial strategies significantly more frequently, even though they rated their own psychosocial skills lower. Among both physicians and nurses, diabetes specialists were significantly more likely than generalists to utilize psychosocial strategies. Physicians and nurses used psychosocial strategies significantly more when they believed that more patients have psychosocial problems and that problems interfere more with diabetes control. Referral to psychosocial specialists was significantly more likely when physicians and nurses perceived that professional psychological resources were more available. There were substantial country differences in all factors studied. Compared with other countries, U.S. providers provided more psychosocial care themselves but were less likely to refer to psychosocial specialists. CONCLUSIONS: Psychosocial strategies are important parts of the diabetes care provider repertoire; understanding their determinants may facilitate efforts to increase their use.     

Effective communication and delivery of culturally competent health care

Effective communication between patients and health care providers is a critical element to quality health care. Becoming aware of patients' attitudes, beliefs, biases, and behaviors that may influence patient care can help clinicians improve access to and quality of care. Health care providers should develop a strategic plan for improvement, then implement and evaluate the plan to include structured, continuously improving progress toward achieving cultural competency goals. In this challenging health care environment, health care providers need the skills to explore the meaning of illness, to determine patient's social and family context, and provide patient-centered and culturally competent care.