A framework for cultural competence in health care organizations

Increased racial and ethnic diversity in the United States brings challenges and opportunities for health care organizations to provide culturally competent services that effectively meet the needs of diverse populations. The need to provide more culturally competent care is essential to reducing and eliminating health disparities among minorities. By removing barriers to cultural competence and placing a stronger emphasis on culture in health care, health care organizations will be better able to address the unique health care needs of minorities. Organizations should assess cultural differences, gain greater cultural knowledge, and provide cultural competence training to deliver high-quality services. This article develops a framework to guide health care organizations as they focus on establishing culturally competent strategies and implementing best practices aimed to improve quality of care and achieve better outcomes for minority populations.     

Increasing awareness and implementation of cultural competence principles in health professions education

Even as the importance of improved communication between health professionals and patients grows, the factors making it more difficult continue unabated--everything from expanding medical technology and increased subspecialization to America's ever-increasing cultural diversity. This article looks at some of the ways health care professionals, administrators, accreditors, and educators across the continuum of medical and health-related professions are seeking to increase the cultural competence skills of current and future practitioners. Many of these efforts, however, are still too recent and limited to produce measurable results. Data on the implementation of educational standards and curricula need to be collected, analyzed, and disseminated to begin to identify the degree to which standards and educational materials are being developed and implemented and what, if any, impact they are having on the delivery of culturally effective care.     

Determining and maintaining competence: an obligation of allied health education

In a climate of growing concern about the costs and quality of health care, there is increasing evidence that the health care system lacks effective controls to assure the continuing competence of health practitioners. The assumption that educational institutions, and specifically those that prepare allied health professionals, can meet obligations to the clinical community and the public by means of the present haphazard system of voluntary continuing education is questioned. Instead, the author suggests that schools of allied health may have to collaborate with professional organizations in identifying individual deficiencies in clinical practice and in offering remedial, continuing education programs that address these deficiencies. The rationale for the assumption of this unique responsibility for determining and maintaining clinical competence by schools of allied health is explored.     

Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care

OBJECTIVES: Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care. METHODS: The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers. RESULTS: Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care. CONCLUSIONS: Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.     

Self-assessment of cultural and linguistic competence in an ambulatory health system

The University Health System (UHS) leaders organized a comprehensive planning process of its ambulatory care system. As part of this planning process, UHS assessed the cultural and linguistic competence of its outpatient environment. This assessment was conducted within the context of standards outlined in the U.S. Department of Health & Human Services (2001) Standards for Cultural and Linguistically Appropriate Services, using a multimethod approach. This multimethod approach included (1) a review of the organizational profile, (2) a review of organizational documents, (3) a review of policies and procedures, (4) clinic site visits, (5) a staff survey, (6) patient and provider focus groups, and (7) interviews with key stakeholders in the community. Generally, the UHS was found to have several strengths that enable it to continue meeting the medical needs of its target populations. To develop greater capacity in the areas of cultural and linguistic competencies, the UHS should continue to promote respect for diversity by focusing on attitudes; beliefs; behaviors; practices; and communication patterns associated with race, ethnicity, religion, socioeconomic status, historical and social context, physical or mental ability, age, gender, sexual orientation, generational status, and acculturation level. Recommendations for achieving a more culturally competent healthcare organization are provided.     

Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education

Researchers and program developers in medical education presently face the challenge of implementing and evaluating curricula that teach medical students and house staff how to effectively and respectfully deliver health care to the increasingly diverse populations of the United States. Inherent in this challenge is clearly defining educational and training outcomes consistent with this imperative. The traditional notion of competence in clinical training as a detached mastery of a theoretically finite body of knowledge may not be appropriate for this area of physician education. Cultural humility is proposed as a more suitable goal in multicultural medical education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.     

Application of an intersectional framework to understanding the association of disability and sexual orientation with suicidal ideation among Oregon Teens

BackgroundSuicide is the second leading cause of death among U.S. youth. Prior research has found that disability and sexual orientation are each independently associated with suicide risk. However, most analyses regarding sexual orientation or disability in relation to teenagers’ health have isolated the effects of these identities via multiple regression models. That approach assumes there is no multiplicative or synergistic effect between the two identities.ObjectiveTo examine the association between suicidal ideation and the intersection of disability and sexual orientation.MethodsCross-sectional data from the 2015 Oregon Healthy Teens Survey were analyzed using Poisson regression analysis with robust variance to estimate the relationship between the intersection of disability and sexual orientation and youth reports of suicidal ideation. We calculated three measures of interaction: 1) the excess risk due to interaction (RERI); 2) the proportion attributable to interaction (AP); and 3) the synergy index (SI).ResultsSexual minority teenagers with disabilities had higher risk of suicidal ideation (adjusted relative risk [ARR] = 2.82, 95% CI: 2.47–3.21) with respect to heterosexual teenagers without disabilities. The risk was also elevated, to a lesser degree, for heterosexual youth with disabilities (ARR = 1.97, 95% CI: 1.78–2.19) and LGB youth without disabilities (ARR = 2.17, 95% CI: 1.95–2.42) with respect to the reference group. Our measures of interaction were indicative of a synergistic effect between disability and sexual orientation.ConclusionsOur findings suggest the combination of disability and minority sexual orientation may be associated with compounded negative experiences that could exacerbate the risk of suicide.     

Inequity in disability pension: an intersectional analysis of the co-constitution of gender,education and age. The Hordaland Health Study

Social position, education, gender and increasing age are all identified as important risk factors for disability pension. This study takes an intersectionality approach and examines their co-constitution, in relation to inequity in disability pension. The population included 22,203 middle-aged men and women participating in the community-based Hordaland Health Study, Western Norway (1997–1999). The participants were categorised in four exposure groups: higher educated men, higher educated women, lower educated men and lower educated women. The outcome was disability pension from 1992 to end of 2007, from a national registry. Using recommendations for intersectionality-informed quantitative research, we estimated the main effects of gender and educational attainment on disability pension, and potential statistical multiplicative interactions between gender and education in relation to cause-specific and all-cause disability pension. For all-cause disability pension, men with higher education had the lowest risk for disability pension (rate per 1000 person-years: 2.01) during the course of working life (from age 35 to 57), followed by higher educated women (rate 3.56), and lower educated men (rate 4.59). Finally, women with lower education had a substantially increased risk already in early middle age (rate 8.39). We found a statistical multiplicative effect of lower education and female gender on all-cause disability pension and disability pension with musculoskeletal disorders compared with men with higher education. The discussion highlights that inequity in disability pension is not only about defining vulnerable groups, but also about understanding how privileges and disadvantages are unequally distributed.     

Death education: enhancing competence across the life span

Life is full of major and minor events analogous to dying and death that few people realize exist. Throughout life there are a variety of loss situations (e.g., death of a pet, divorce, loss of a job, retirement, death of a friend or relative, etc.) that help to prepare individuals for their own death. If death educators can enhance the life skills necessary to cope with these life events, then perhaps, the individual will be better able to cope with their own death and the death of a significant other. This paper will present an overview of the basic tenets of life span intervention, provide a discussion of life skills directly related to dying and death, and suggest key points of positive intervention.     

Developing an education and assessment framework for the Foundation Programme

AIM: To develop an education and assessment framework for the second year of the Foundation Programme (F2). METHODS: A total of 23 PRHOs were recruited to the F2 pilot in August 2003. The training posts included a variety of specialties at 2 hospital trusts plus primary care. Trainee expectations and satisfaction were evaluated using questionnaires administered before and at the end of the pilot. At the end of the pilot, 10 trainees participated in a focus group and 19 trainers participated in a semistructured telephone interview. RESULTS: The majority of trainees (78%) felt that their expectations of the F2 pilot were met and all felt that they had improved their generic skills. Attendance at the generic education programme was 95%. The majority of trainees found the assessment framework useful. The percentage of undecided trainees in terms of career aspirations dropped from 48% to 13%. Trainees valued the breadth of experience provide by the year and the support provided by the programme directors and each other. A need for better communication, administrative support and time for assessment was highlighted by the trainers. CONCLUSIONS: Early, focused education on generic skills will benefit both doctors and their patients. More varied career experience will help to ensure that doctors make appropriate and timely career decisions. Pilots are identifying good practice and areas that need improvement.     

Reducing healthcare disparities in the military through cultural competence

Healthcare disparities are fast encroaching upon equal access healthcare systems like the military. While this growth has been attributed to the same antecedents as those found in the general civilian population, four additional assumptions are posited as contributing factors to healthcare disparities that are peculiar to the military. Research on certain segments of the veteran population in the Veterans Administration (VA) is profiled as the most analogous healthcare system to that of the military's and a meta-analysis of studies on similar populations in the military are also examined. Like the general civilian population, cultural competence is viewed as an imperative component of healthcare delivery to help to narrow the healthcare disparities gap between majority (men and whites) and minority (women and nonwhites) populations in the military.