Improving Cultural Competence to Reduce Health Disparities for Priority Populations (2022)

Research Protocol ARCHIVED Jul 8, 2014

Table of Contents

Archived: This report is greater than 3 years old. Findings may be used for research purposes, but should not be considered current.

(Video) Reducing Health Disparities through Organizational Cultural Competence

Background and Objectives for the Systematic Review

Reducing health disparities and achieving equitable health care remains an important goal for the U.S. healthcare system. Cultural competence is widely seen as a foundational pillar for reducing disparities through culturally sensitive and unbiased quality care. Culturally competent care is defined as care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.1 The Office of Minority Health, Department of Health and Human Services, established national standards for culturally and linguistically appropriate services in health and health care (National CLAS Standards) to provide a blueprint to implement such appropriate services to improve health care in the U.S.2 The standards cover areas such as governance, leadership, workforce; communication and language assistance; organizational engagement, continuous improvement, and accountability.

A lack of conceptual clarity around cultural competence persists in the field and the research community. There is confusion about what cultural competence means, and different ways in which it is conceptualized and operationalized. This confusion leads to disagreement regarding the topic areas and practices in which a provider should train to attain cultural competence.3 The populations to which the term cultural competence applies are also ill-defined. Cultural competence is often seen as encompassing only racial and ethnic differences, omitting other marginalized population groups who are ethnically and racially similar to a provider but who are at risk for stigmatization or discrimination, are different in other identities, or have differences in healthcare needs that result in health disparities. This broader concept may be termed diversity competence. In keeping with this broader view and AHRQ’s commitment to a comprehensive approach to priority populations, this systematic literature review considers, alongside race and ethnicity, two of these less considered populations: persons with disabilities and persons identifying as lesbian, gay, bisexual, transgender, queer/questioning, and/or intersex (LGBTQI).

The most popular and most well studied type of cultural competence intervention is cultural competency training for healthcare providers. Two general approaches have been used in creating educational interventions to address cultural competence: programs aimed at improving knowledge that is group-specific, and programs that apply generic or universal models. Concerns have been raised about cultural competency programs that use a group-specific approach to teach providers about the attitudes, values, and beliefs of a specific cultural group leading to stereotyping and oversimplifying the diversity within a particular priority group.4 The universal approach to training proposes that cultural competence can be taught through reflective awareness, empathy, active listening techniques, and the cognitive mechanisms contributing to cultural insensitivity or blindness, such as implicit biases or stereotype threats. Therefore, of interest is identifying the effect of varying types of cultural competence training on patient-level outcomes.

In addition to education and training, changing clinical environments can also be key to purposeful change in behavior. The National CLAS includes several standards that address the organizational level rather than the patient/provider relationship.1 Changes in provider knowledge, attitudes, and skills is a necessary step, but for those gains to translate into culturally competent behaviors there also needs to be changes in the structures and culture of health care systems and organizations. This review is intended to focus on the effectiveness of interventions and the provider and system level, but not at the level of policy which, while important, is beyond the scope of this review.

What outcomes are considered high priority and final patient-centered outcomes differ by priority population. For example, while access is important to all priority populations, people from the disability culture may face multiple levels or forms of access barriers, such as transportation to facilities and whether the exam room and its contents is physically accessible. Similarly, linguistic competence means something different to a provider treating a person for whom English is a second language than to a provider treating a transgendered person.

Comparative effectiveness reviews evaluate the evidence for both benefits and harms, or adverse effects, of interventions in order to provide decisionmakers with the balance of net benefits. In the case of cultural competence interventions, harms may include unintended consequences of an intervention. For example, while cultural competence interventions often aim to improve cultural sensitivity by reducing stereotyping and stigma, there remains the possibility that some interventions may inadvertently induce different stereotyping behaviors by inducing a provider to create new scripts, or ways of categorizing people, that result in negative consequences.

The review was requested by Senior Advisors in AHRQ’s Division of Priority Populations. The request originally derived from general concerns regarding pervasive disparities in care for adults and children that may be associated with gender, disability and race/ethnicity. In addition, the consideration of cultural competence is usually focused on racial or ethnic minority adults, thus creating a gap in evidence-based information in racial or ethnic minority children, persons with disabilities, and LGBTQI people. This systematic literature review will consider the effect of cultural and diversity competence interventions on three populations with varying degrees of cultural identification and visibility: LGBTQI adolescents and adults, children and adults aging with disabilities, and racial/ethnic minority children and adults.

As noted previously, cultural competence is challenging to isolate as a concept. The concept of cultural competence overlaps with several other concepts related to providing high-quality, appropriate care. Figure 1 provides an illustration of a few of these overlapping concepts. When conducting systematic review, clarity in discriminating between interventions within the scope of cultural competence versus those outside is important. The review’s main focus is on whether cultural competency interventions change the clinicians’ behaviors (such as communication and clinical decisionmaking), the patient-provider relationship, and/or clinical systems to result in better outcomes for patients from the priority populations. Some public health outreach activities, (such as community-based HIV education in underserved, African American neighborhoods or school-based empowerment programs for young people with disabilities), may address an unmet need. However, such studies will not be included in this review, as our focus is on the patient-provider interaction and the system of care surrounding that interaction. Within the clinical context, interventions aimed at improving care for all patients (such as patient-centered care, patient-centered medical home, health literacy), are excluded unless the intervention is specifically tailored to one of the populations of interest in this review. Because patients are also participants in the system, interventions at the provider or system level that help patients competently navigate the patient-provider relationship and/or the health system are also of interest. This review is focused on interventions that promote equity, the primary outcomes of interest are reductions in disparities between populations for a given health outcome measure.

Figure 1. Health services research concepts that overlap with cultural competence

Improving Cultural Competence to Reduce Health Disparities for Priority Populations (1)

Includable interventions that lie within the Cultural Competence circle in Figure 1 are defined as:

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  • “People first” care interventions that promote “individuation.” These interventions prompt providers to make a conscious effort to view people in terms of their individual characteristics rather than group membership, and being aware of one’s own biases and stereotypes. The interventions can also take place at the system level, engineering a system that promotes providing needed care universally, such as equitable receipt of preventive or chronic disease management.
  • Cultural competence interventions that improve the ability of providers to provide health care services to patients who are unlike the providers (or the providers’ culture) in important ways. Targeted providers in such cases can include physicians, nursing staff, allied health professionals, paraprofessionals, and clinic staff who have regular contact with patients, or health system factors intended to engineer the system to support and sustain cultural competence.
  • Interventions that assist patients from priority populations to competently navigate the patient-provider relationship and the larger health system
  • Interventions that address physical barriers to access.
  • Interventions that educate providers about, and to look for, the common secondary conditions specific to the target populations. For example, people with disabilities commonly experience an identifiable set of health conditions secondary to the disability such as urinary tract infections, asthma, obesity, hypertension, and pressure ulcers.5

As the overlapping circles in Figure 1 suggest, there are also interventions encompassed in meeting underserved needs that are not within the scope of this review, such as interventions to address access problems due to finance/insurance coverage issue (such as Medicare/Medicaid), and general health literacy interventions.

Key Questions

Key questions, PICOT, and analytic framework were posted for public comment from February 6, 2014 to February 26, 2014. In response to comments provided, we made several changes. Outcomes of interest were expanded and specified for each priority population. Young adults/transitional aged youth were added to the LGBTQI population as a subgroup of interest. Key Question 5 was rewritten to better fit systematic review methods focused on interventions targeted at the organization and structure level, which can include the built environment.

Question 1

What models have been used to conceptualize cultural competence and culturally appropriate care in health contexts, and how do those models compare?

Question 2

What is the effectiveness of interventions to improve culturally appropriate care for LGBTQI adolescents (ages 13-17), young adult (18-25), and adults?

A. Provider intermediate outcomes

  • Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes
  • Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization
  • Improved specific knowledge of health needs unique to LGBTQI community
  • Provider behavior, such as clinical decision-making, communication

B. Patient intermediate outcomes

  • Patient learning/knowledge, including linguistic competence regarding gender-diversity
  • Improved access to health services
  • Utilization of health services
  • Patient experience and satisfaction, such as improved perceptions of care
  • Patient health behaviors, such as tobacco use or health seeking behaviors
  • Use of preventive services

C. Final health or patient-centered health outcomes, including but not limited to:

  • Improved mental health outcomes, such as depression, anxiety, suicidality, peer/familial/intimate relationships, substance use
  • Improved medical health outcomes, such as reduction in obesity, improved sexual health
  • Adverse events; unintended negative consequences of intervention

Question 3

What is the effectiveness of interventions to improve culturally appropriate health care for children and adults with disabilities?

A. Provider intermediate outcomes

  • Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes, willingness to serve and perceived competence in service people with disabilities
  • Provider behavior, such as clinical decision-making, communication
  • Provider beliefs/cognitions the priority population, such as reducing stereotyping and stigmatization

B. Patient intermediate outcomes

  • Improved access to health services
  • Utilization of health services
  • Patient experience and satisfaction, such as improved perceptions of care

C. Final health or patient-centered health outcomes, including but not limited to:

  • Improved mental health outcomes, such as depression, substance use
  • Improved medical health outcomes, such as reduction in obesity, metabolic disorders, heart disease, breast cancer
  • Patient health behaviors, such as tobacco use or health seeking behaviors
  • Use of preventive services, and other access to care measures

D. Adverse effects; unintended negative consequences of interventions

Question 4

What is the effectiveness of interventions to improve culturally appropriate health care for racial/ethnic minority children and adults?

A. Provider intermediate outcomes

  • Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes, willingness to serve and perceived competence in service people with disabilities
  • Provider behavior, such as clinical decision-making, communication
  • Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization

B. Patient intermediate outcomes

  • Patient beliefs/attitudes such as improved trust, perceived racism
  • Utilization of health services
  • Patient experience and satisfaction, such as improved perceptions of care
  • Patient health behaviors, such as tobacco use or health seeking behaviors
  • Use of preventive services, and other access to care measures

C. Final health or patient-centered health outcomes, including but not limited to:

  • Improved mental health outcomes, such as depression, substance use
  • Improved medical health outcomes, such as reduction in obesity, kidney disease, heart disease, breast cancer, sickle cell disease

D. Adverse effects; unintended negative consequences of interventions

Question 5

What is the effectiveness of organizational or structural interventions for promoting culturally appropriate care for each of the priority populations across providers?

PICOTS

Table 1. PICOTS
PICOTSKQ2KQ3KQ4KQ5
PopulationLGBT adolescents (ages 13-17), young adults (ages 18-25) and adultsChildren and adults with disabilities, with older adults, focus on aging with a disability, rather than aging into a disability.Racial/ethnic children and adultsBased on populations for KQs 2-4
Intervention
  • Cultural competence/ culturally appropriate care provider education and training
  • Cultural competence/ culturally appropriate care clinic-based interventions targeted to patients
  • Cultural competence/ culturally appropriate care clinic-based interventions targeted to providers
Same as KQ2Same as KQ2Cultural competence/ culturally appropriate care interventions targeted at the organizational level, including physical/ environmental factors.
Comparator groups
  • Usual care
  • Head-to-head trials of different strategies
Same as KQ2Same as KQ2Same as KQ2
OutcomesIntermediate outcomes
  • Provider training and motivation outcomes (competencies, knowledge, changes in attitudes)
  • Provider behavior, such as clinical decision-making, communication
  • Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization
  • Provider improved specific knowledge of health needs unique to LGBT community
  • Patient learning/ knowledge
  • Utilization of health services
  • Patient experience/ satisfaction
  • Patient health behaviors
  • Use of preventive services and other access to care measures
Final health or patient-centered outcomes – reduced disparities in terms of:
  • Patient medical care outcomes
  • Patient mental health care outcomes (depression, anxiety, suicidality, substance use, peer/familial/ intimate relationships)
Adverse effects of intervention(s)
  • Unintended negative consequences of intervention
Intermediate outcomes
  • Provider training and motivation outcomes (competencies, knowledge, changes in attitudes)
  • Provider behavior, such as clinical decision-making, communication
  • Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization
  • Improved access to health services
  • Utilization of health services
  • Patient experience/satisfaction
Final health or patient-centered outcomes – reduced disparities in terms of:
  • Patient medical care outcomes
  • Patient mental health care outcomes (depression, substance use)
  • Patient health behaviors
  • Use of preventive services and other access to care measures
Adverse effects of intervention(s)
  • Unintended negative consequences of intervention
Intermediate outcomes
  • Provider knowledge, attitudes, and competencies (skills) in providing culturally competent health care
  • Provider behavior, such as clinical decision-making, communication
  • Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization
  • Patient beliefs/cognitions such as improved trust, perceived racism
  • Improved access to health services
  • Utilization of health services
  • Patient experience/satisfaction
  • Patient health behaviors
  • Use of preventive services and other access to care measures
Final health or patient-centered outcomes – reduced disparities in terms of:
  • Patient medical care outcomes
  • Patient mental health care outcomes (depression, substance use)
Adverse effects of intervention(s)
  • Unintended negative consequences of intervention
Intermediate organizational adaptation outcomes
  • Process measures
  • Availability of culturally competent health care across population groups
  • Structural changes
TimingVariable – depends on the purpose of the interventionSame as KQ2Same as KQ2Same as KQ2
SettingUS inpatient, outpatient, and community settings in which patients from priority populations are interacting with healthcare providersSame as KQ2Same as KQ2Same as KQ2

Analytic Framework

Figure 2. Analytic framework for improving cultural competence to reduce disparities in priority populations

Improving Cultural Competence to Reduce Health Disparities for Priority Populations (2)

NOTE: Details of specific outcomes for a specific priority population can be found in Table 1.

Methods

A. Criteria for Inclusion/Exclusion of Studies in the Review

Studies will be included in the review based on the PICOTS framework outlined in Table 1 and the study-specific inclusion criteria described in Table 2.

Table 2. Study inclusion criteria
CategoryCriteria for Inclusion
Study Enrollment
  • Studies of any of the priority populations; LGBTQI, disability, race/ethnic groups
  • Studies examining interventions to improve gender sensitivity that is, women as a population, rather than the listed priority populations, will be excluded.
Study Design and Quality
  • Systematic reviews, RCTs, nonrandomized controlled trials, and prospective and retrospective cohort studies with comparators, before/after case reports with comparators, and interrupted time series will be included for each population and treatment option.
  • Studies specifically addressing treatment harms may also include retrospective and case series designs.
  • Systematic reviews must include risk of bias assessment with validated tools.
Includable models
  • Structured depiction of factors or components that describe cultural competence defined as “as care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.”
  • We will exclude models at organizational or system level that do not suggest possible points of intervention.
Time of PublicationSearch all literature 1990 forward. Cultural competence as a concept and concerned gained traction in the published literature during the early 1990s.
Publication typePublished in peer reviewed journals, grey literature sourced from governmental or research organizations
Language of PublicationEnglish

B. Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies to Answer the Key Questions

We will search Ovid Medline, Ovid PsycInfo, and the Cochrane EPOC to identify previous studies published and indexed in bibliographic databases from 1990 forward. Our search strategy, which appears in Appendix A, was created by staff and a biomedical librarian, and reviewed by a second independent librarian. Our search strategy included relevant medical subject headings and natural language terms for each of the priority populations and the concept of cultural competence. The concept terms were combined with filters to select relevant RCTs, observational studies, and systematic reviews.

Given the lack of specific and agreed-upon terms that capture cultural competence and the priority populations, and the diffused state of the literature, we will approach the search process strategically, using both inductive and deductive approaches. We will examine the LGBT literature first as a relatively easier priority group but one that does not necessarily refer to itself as a “culture” to define through keyword searches for lessons learned regarding natural language use that may help with capturing disability populations not otherwise easily identifiable as a “culture.” Likewise, identified relevant LGBT cultural competence literature may also serve to help identify extensions of natural language terms for keyword search terms to use for cultural competence in the disability literature. Much of the cultural competence literature grew out of concern for the racial/ethnic implications and the terms used for racial/ethnic groups do not translate well to other priority groups that do not necessarily self-identify as a culture. We will also iteratively return to bibliographic databases to search the literature as new terms are uncovered or new relevant interventional approaches are discovered.

As bibliographic database searches are completed for each priority group, we will review the search results for studies relevant to our PICOTS framework and study-specific criteria. The literature set identified at this phase will be examined from a content analysis perspective for emerging themes. Focused searches will then be developed to specifically search for further examples of that intervention theme in the literature.

Search results will be downloaded to EndNote.6 Titles and abstracts will be reviewed by two independent investigators to identify studies meeting PICOTS framework and inclusion/exclusion criteria. All studies identified as relevant by either investigator will undergo full-text screening. Two investigators will independently screen full text to determine if inclusion criteria are met. Differences in screening decisions will be resolved by consultation between investigators, and, if necessary, consultation with a third investigator. We will document the inclusion and exclusion status of citations undergoing full-text screening. Throughout the screening process, team members will meet regularly to discuss training material and issues as they arise to ensure consistency of inclusion criteria application.

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Bibliographic database searches will be supplemented with backward citation searches of highly relevant systematic reviews. We will also share search results with the TEP for ask for themes which may have been missed in the initial searches. We will update searches while the draft report is under public/peer review.

We will conduct additional grey literature searching to identify other search efforts into the priority populations or cultural competence for further MeSH or natural language keyword search terms. Relevant grey literature resources include trial registries and governmental or research organizations. We will search ClinicalTrials.gov and HSRProj for ongoing or completed studies.

C. Data Abstraction and Data Management

Studies meeting inclusion criteria will be distributed among investigators for data extraction. One investigator will extract relevant study, population demographics, and outcomes data. Data fields to be extracted will be determined based upon proposed summary analysis. These fields will include author, year of publication; setting, author definition of cultural competence, subject inclusion and exclusion criteria, intervention and control characteristics (intervention definition and components, timing, frequency, duration, fidelity), followup duration, participant baseline demographics, enrollment, descriptions and results of primary outcomes and adverse effects, and study funding source. Relevant data will be extracted into extraction forms created in Excel. Evidence tables will be reviewed and verified for accuracy by a second investigator.

We will use data from relevant comparisons in previous systematic reviews to replace the de novo extraction process when the comparison is sufficiently relevant. Data elements abstracted from included systematic reviews, whether the elements are at the individual study or systematic review levels, will depend on how the systematic review will be used. Use may range using individual elements to updating a review, to using the review without modification. Only systematic reviews that assess included study risk of bias will be assessed for review quality. Systematic reviews with fair or good methodology will be used. Systematic reviews that are deemed to have potential author conflict of interest, such as due to reviewing a body of literature to which the authors had substantially contributed, will be subjected to random quality checks of 10 percent of included study data abstraction. RCTs in included systematic reviews will be tracked for contribution to unique population/treatment/outcome comparisons to avoid double-counting study results.

D. Assessment of Methodological Risk of Bias of Individual Studies

Risk of bias of eligible studies will be assessed using instruments specific to study design. For RCTs, questionnaires developed from the Cochrane Risk of Bias tool will be used. The seven domains included in this tool include sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data (i.e., was incomplete outcome data adequately addressed), selective reporting, and other sources of bias (i.e., problems not covered by other domains). Additional items will be developed to assess potential risk-of-bias not addressed by the Cochrane tool. Outcomes measurement issues inherent in the psychometric properties of the questionnaires used to measure outcomes and assessment methods used to detect change in those questionnaire results will be specifically evaluated for detection bias. Additional items may be necessary to evaluate potential risk-of-bias associated with treatment definition and implementation (treatment fidelity). Specific study methodology or conduct will be used to judge potential risk of bias with respect to each domain following guidance in the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0.7

We developed an instrument for assessing risk of bias for observational studies based on the RTI Observational Studies Risk of Bias and Precision Item Bank.8 We selected items most relevant in assessing risk of bias for this topic, including participant selection; attrition, ascertainment, and appropriateness of analytic methods. The preliminary risk of bias assessment form is provided in Appendix B. The form will be tested by investigators, with particular attention to project term definitions, using an initial sample of included studies and will be finalized by full team input.

Two investigators will independently assess risk of bias for all included studies. Investigators will consult to reconcile any discrepancies in overall risk of bias assessments. Overall summary risk of bias assessments for each study will be classified as low, moderate, or high based upon the collective risk of bias inherent in each domain and confidence that the results are believable given the study’s limitations. When the two investigators disagree, a third party will be consulted to reconcile the summary judgment. Outcomes in studies assessed as having a high risk of bias will be compared to synthesized evidence as a means of sensitivity analysis. Contradictions will be investigated in further depth.

Systematic review quality and risk of bias will be assessed using modified AMSTAR criteria.9 Study-level risk of bias must be assessed using validated risk of bias tools appropriate to study design. Since AMSTAR was not originally created as a quality review tool, an additional question regarding whether the review findings logically follow from the contributing studies will be added.

E. Data Synthesis

We will summarize the results into evidence tables and synthesize evidence for each unique population, comparison, and outcome combination. When a comparison is adequately addressed by a previous systematic review of acceptable quality and no new studies are available, we will reiterate the conclusions drawn from that review. When new trials are available, previous systematic review data will be synthesized with data from additional trials.

We will summarize included study characteristics and outcomes in evidence tables. We do not expect pooling to be appropriate due to lack of comparable studies or heterogeneity; qualitative synthesis will be conducted in these instances. Observational literature examining treatment benefits will be used for subgroups not covered by published RCTs. We will treat cultural tailoring/targeting studies as a separate literature group that provides context for or informs current or possible future cultural competence intervention research.

The following matrixes provide a basic framework by which intervention population targets and general categories of measures may be assessed. Each of the cells may be exploded into another matrix of relevant details. Likewise, each of the outcome categories listed here may be exploded for finer detail. For example, we will distinguish between medical and mental health services, for patient intermediate outcomes. Provider types, if information is available in the literature, may be another useful way to contrast information, particularly for ethnicity- or gender-based care providers. Individual provider versus team approaches will be examined separately. We will also differentiate between models for undergraduate and graduate medical and health care education as compared to “re-training” existing providers.

Table 3. Overall outcome framework
Individual and Structural Level Outcomes*LGBT
13-17 yr old
LGBT
18-25 yr old
LGBT
Adult
Disability
Children
Disability
Adult
Race/Ethnic
Children
Race/Ethnic
Adult
*Refer to Table 1 for a complete list of provider, patient and organizational outcomes.
Intermediate Provider Outcomes
Intermediate Patient Outcomes
Intermediate organizational outcomes- structural changes and availability of culturally competent healthcare across system
Final Patient-Centered Outcomes- improved medical and mental health

We will explore second order interactions if literature is identified allowing such examination. For example, we will look for intersections of disability and race, or LGBT and race, or LGBT and disability priority populations. We will also separate analyses by subgroups within the priority populations, such as different LGBT identities, if the literature provides such information.

Should there be sufficient literature available for possible pooling, decisions for pooling will be based on the homogeneity of study populations based on inclusion criteria, specific interventions, and the ability to treat outcome measures as similar. Data will be analyzed in RevMan 5.2110 software. Observational literature examining treatment benefits will be used for subgroups not covered by published RCTs. Using a random effects model, we will calculate risk ratios (RR) and absolute risk differences (RD) with the corresponding 95 percent confidence intervals (CI) for binary primary outcomes. Weighted mean differences (WMD) and/or standardized mean differences (SMD) with the corresponding 95 percent CIs will be calculated for continuous outcomes. We will assess the clinical and methodological heterogeneity and variation in effect size to determine appropriateness of pooling data.11 If data are appropriate for pooling, meta-analysis will be performed. We will assess statistical heterogeneity with Cochran’s Q test and measure magnitude with I2 statistic.11

For KQ 1, we will compare model characteristics. The results of this comparison may be used to organize results for KQ2-5.

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F. Grading the Strength of Evidence (SOE) for Major Comparisons and Outcomes

The overall strength of evidence for primary outcomes of KQ2-5 within each comparison will be evaluated based on four required domains: (1) study limitations (risk of bias); (2) directness (single, direct link between intervention and outcome); (3) consistency (similarity of effect direction and size); and (4) precision (degree of certainty around an estimate).12 A fifth domain, reporting bias, will be assessed when SOE based upon the first four domains is moderate or high.12 Based on study design and conduct, risk of bias will be rated as low, medium, or high. Consistency will be rated as consistent, inconsistent, or unknown/not applicable (e.g., single study) based on the direction, magnitude, and statistical significance of all studies. Directness will be rated as either direct or indirect based on the need for indirect comparisons when inference requires observations across studies. Precision will be rated as precise or imprecise based on the degree of certainty surrounding each effect estimate or qualitative finding. An imprecise estimate is one for which the confidence interval is wide enough to include clinically distinct conclusions. Other factors that may be considered in assessing strength of evidence include dose-response relationship, the presence of confounders, and strength of association. Based on these factors, the overall strength of evidence for each outcome will be rated as:12

  • High: Very confident that estimate of effect lies close to true effect. Few or no deficiencies in body of evidence, findings believed to be stable.
  • Moderate: Moderately confidence that estimate of effect lies close to true effect. Some deficiencies in body of evidence; findings likely to be stable, but some doubt.
  • Low: Limited confidence that estimate of effect lies close to true effect; major or numerous deficiencies in body of evidence. Additional evidence necessary before concluding that findings are stable or that estimate of effect is close to true effect.
  • Insufficient: No evidence, unable to estimate an effect, or no confidence in estimate of effect. No evidence is available or the body of evidence precludes judgment.

We will assess strength of evidence for published systematic reviews replacing de novo review processes that did not provide a strength of evidence assessment based on a GRADE or GRADE-equivalent method.

We will assess strength of evidence for outcomes drawn from more than one study for a given patient population/intervention/outcome comparison. For outcomes drawn from a single study, given the low probability that such a study is of large sample size, we will only assess strength of evidence for studies of low risk of bias. Results and risk of bias will be presented for other reported included studies to provide information across the full spectrum of included studies. However, results of studies not undergoing strength of evidence assessment will be identified as hypothesis generating, rather than hypothesis testing, in nature.

G. Assessing Applicability

Cultural competence intervention research by definition generally draws on defined priority populations, and very possibly specific subgroups of those priority populations. To the extent that similar interventions are tested in multiple studies across priority population groups, we will be able to suggest generalizability across those groups. Otherwise generalizability will be narrowly subscribed by the study populations. Applicability of studies will be determined according to the PICOTS framework. Study characteristics that may affect applicability include, but are not limited to, the population from which the study participants are enrolled, and patient or intervention characteristics different than those described by population studies of the priority populations or types of organizational settings. We will pay special attention to defined subgroups that are at the intersections of two or more priority populations. These applicability issues are present in the synthesis frameworks and sensitivity analyses described in more detail in the data synthesis section.

References

  1. What Are CAHPS Supplemental Items?Accessed November, 15, 2013
  2. Office of Minority Health, U.S. Department of Health and Human Services. The National CLAS Standards. Last Accessed May 29, 2013.
  3. Gregg J, Saha S. Losing culture on the way to competence; the use and misuse of culture in medical education. Academic Medicine. 2006;81(6):542-7
  4. Betancourt, Joseph R. MD, MPH; Green, Alexander R. MD, MPH. Commentary: Linking Cultural Competence Training to Improved Health Outcomes: Perspectives From the Field. Academic Medicine Issue: Volume 85(4), April 2010, pp 583-585
  5. Kinne S, Patrick DL, Doyle DL. Prevalence of secondary conditions among people with disabilities. American Journal of Public Health. 2004 Mary:94(3):443-5
  6. EndNote Vers X.6 2014 Thomson Reuters.
  7. Higgins JPT, Altman D, Sterne J. Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions: Version 5.1.0. The Cochrane Collaboration; 2011.
  8. Viswanathan M, Berkman ND. Development of the RTI item bank on risk of bias and precision of observational studies. Journal of Clinical Epidemiology. 2011.
  9. White C, Ip S, McPheeters M, et al. Using existing systematic reviews to replace de novo processes in conducting Comparative Effectiveness Reviews Agency for Healthcare Research and Quality. Rockville, MD: 2009.
  10. Review Manager (RevMan) [Computer program]. Version 5.2. Copenhagen: The Nordic Cochrane Centre TCC, 2012.
  11. Fu R, Gartlehner G, Grant M, et al. Conducting quantitative synthesis when comparing medical interventions: AHRQ and the Effective Health Care Program. Journal of Clinical Epidemiology. 2011 Nov;64(11):1187-97. PMID 21477993.
  12. Methods Guide for Comparative Effectiveness Reviews. AHRQ Publication No. 13(14)-EHC 130-EF, Grading the strength of a body of evidence when assessing health care interventions for the effective health care program of the Agency for Healthcare Research and Quality: An update. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

Definition of Terms

Not applicable.

Summary of Protocol Amendments

If we need to amend this protocol, we will give the date of each amendment, describe the change and give the rationale in this section. Changes will not be incorporated into the protocol.

Review of Key Questions

AHRQ posted the key questions on the Effective Health Care Website for public comment. The EPC refined and finalized the key questions after review of the public comments, and input from Key Informants and the Technical Expert Panel (TEP). This input is intended to ensure that the key questions are specific and relevant.

Key Informants

Key informants are the end users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Within the EPC program, the key informant role is to provide input into identifying the Key Questions for research that will inform healthcare decisions. The EPC solicits input from key informants when developing questions for systematic review or when identifying high priority research gaps and needed new research. Key informants are not involved in analyzing the evidence or writing the report and have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.

Key informants must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their role as end-users, individuals are invited to serve as key informants and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Technical Experts

Technical experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicting opinions are common and perceived as health scientific discourse that results in a thoughtful, relevant systematic review. Therefore study questions, design, and methodological approaches do not necessarily represent the views of individual technical and content experts. Technical experts provide information to the EPC to identify literature search strategies and recommend approaches to specific issues as requested by the EPC. Technical experts do not do analysis of any kind nor do they contribute to the writing of the report. They have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.

Technical experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as technical experts and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Peer Reviewers

Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodological expertise. The EPC considers all peer review comments on the draft report in preparation of the final report. Peer reviewers do not participate in writing or editing of the final report or other products. The final report does not necessarily represent the views of individual reviewers. The EPC will complete a disposition of all peer review comments. The disposition of comments for systematic reviews and technical briefs will be published three months after the publication of the evidence report.

Potential peer reviewers must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Invited peer reviewers may not have any financial conflict of interest greater than $10,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.

EPC Team Disclosures

EPC core team members must disclose any financial conflicts of interest greater than $1,000 and any other relevant business or professional conflicts of interest. Related financial conflicts of interest that cumulatively total greater than $1,000 will usually disqualify EPC core team investigators.

(Video) How to Reduce Health Inequities: Building a True Cultural Competency in Healthcare

Role of the Funder

This project was funded under Contract No. xxx-xxx from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The Task Order Officer reviewed contract deliverables for adherence to contract requirements and quality. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Appendixes

Appendix A. Search algorithms for Cultural Competence

KQ1 Cultural Competence and Theoretical Models
#Searches
1culture/
2cultural competency/
3anthropology cultural/
4cultural characteristics/
5cultural diversity/
6cross-cultural comparison/
7(cultur* adj3 (competenc* or understand* or knowledge* or expertise or skill* or sensitiv* or aware* or appropriate* or acceptab* or safe* or humility or communicat* or barrier* or divers* or comparison* or identity or specific or background* or value* or belief*)).tw.
8transcultural nursing/
9(intercultural* or inter-cultural or transcultural* or trans-cultural or cross-cultural or crosscultural or multicultural* or multi-cultural* or multiethnic or bicultural).tw.
10Multilingualism/
11language/
12((linguistic* or language*) adj3 (competenc* or understand* or knowledge* or expertise or skill* or sensitiv* or aware* or appropriate* or acceptab* or safe* or humility or communicat* or barrier* or divers* or comparison* or identity or specific or background* or value* or belief*)).tw.
13(multilingual* or multi-lingual* or bilingual or bi-lingual).tw.
14or/1-13
15exp Models, Nursing/
16exp Models, Theoretical/
17model*.mp. or framework*.tw.
18exp Models, Organizational/
19delivery of health care/
20health knowledge attitudes practice/
21exp Clinical Competence/ or exp Professional Competence/
22or/15-21

KQ2 Study Filters and LGBT Population Terms

  • Lines 1-32 Filter for systematic reviews
  • Lines 33-61 Filter for controlled trials
  • Lines 62-75 Filter for observational studies, including training/education programs
  • Lines 76-88 Population terms
  • Lines 98-100 Intervention terms (used to limit observational studies)
KQ2 Study Filters and LGBT Population Terms
#Searches
1meta analysis as topic/
2meta-analy$.tw.
3metaanaly$.tw.
4meta-analysis/
5(systematic adj (review$1 or overview$1)).tw.
6exp Review Literature as Topic/
7or/1-6
8cochrane.ab.
9embase.ab.
10(psychlit or psyclit).ab.
11(psychinfo or psycinfo).ab.
12or/8-11
13reference list$.ab.
14bibliograph$.ab.
15hand search.ab.
16relevant journals.ab.
17manual search$.ab.
18or/13-17
19selection criteria.ab.
20(data adj2 (extract* or abstract*)).ab.
2119 or 20
22review/
2321 and 22
24Comment/
25Letter/
26editorial/
27animal/
28human/
2927 not (28 and 27)
30or/24-26,29
317 or 12 or 18 or 23
3231 not 30
33randomized controlled trials as topic/
34randomized controlled trial/
35random allocation/
36double blind method/
37single blind method/
38clinical trial/
39clinical trial, phase i.pt.
40clinical trial, phase ii.pt.
41clinical trial, phase iii.pt.
42clinical trial, phase iv.pt.
43controlled clinical trial.pt.
44randomized controlled trial.pt.
45multicenter study.pt.
46clinical trial.pt.
47exp clinical trials as topic/
48or/33-47
49(clinical adj trial$).tw.
50((singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)).tw.
51placebos/
52placebo$.tw.
53randomly allocated.tw.
54(allocated adj2 random$).tw.
55or/49-54
5648 or 55
57case report.tw.
58letter/
59historical article/
60or/57-59
6156 not 60
62exp cohort studies/ or comparative study/ or follow-up studies/ or prospective studies/ or cohort.mp. or compared.mp. or groups.mp. or multivariate.mp.
63cohort$.tw.
64controlled clinical trial.pt.
65exp teaching/
66exp health personnel/ed
67exp teaching materials/
68exp education/
69((education* or teaching or learning or elearning or instruction* or training or skills or didactic or pedagogic* or online or online or web* or internet or cd-rom* or dvd or multimedia or multi-media or computer*) adj2 (intervention* or session* or course* or program* or activit* or presentation* or round* or material* or package* or module* or demonstration* or method* or process*)).tw.
70(inservice or in service or workshop* or (discussion adj1 group*) or lectur* or seminar* or (short adj2 course*) or role play* or immersion or mentor* or lifelong learning or life long learning).tw.
71((staff or professional or workforce or work force) adj (development or training)).tw.
72((medical or continuing or residency or distance) adj2 education).tw.
73((cultural* or transcultural* or multicultural* or intercultural* or bicultural*) adj2 (education or train* or teach* or learn* or instruct* or coach* or skills or content*)).tw.
74(curriculum or curricul* intervent*).tw.
75or/62-74
76exp Bisexuality/ or bisexual*.mp.
77exp Transsexualism/ or transsexual*.mp.
78exp Homosexuality/ or homosexual*.mp.
79exp Transgendered Persons/ or transgender*.mp.
80(lgbt* or glbt*).mp.
81(gay or lesbian).mp.
82("men who have sex with men" or msm or "women who have sex with women" or wsw).mp.
83(WSMW or WSWM or MSWM or MSMW).mp.
84sexual minority.mp.
85gender minority.mp.
86gender expression.mp.
87(gender identit* or sexual orientation or sexual identit*).mp.
88or/76-87
8932 and 88
9061 and 88
9175 and 88
92limit 89 to yr="1990-Current"
93limit 90 to yr="1990-Current"
94limit 91 to yr="1990-Current"
9592 not (93 or 94)
9693 not (92 or 94)
9794 not (92 or 93)
98intervention*.ti,ab.
99program*.ti,ab.
100curriculum.ti,ab.
101or/98-100
10297 and 101

KQ3 Study Filters, Disability Population Terms, and Cultural Competence Terms

  • Lines 1-32 Filter for systematic reviews
  • Lines 33-61 Filter for controlled trials
  • Lines 62-67 Filter for observational studies
  • Lines 68-81 Population terms
  • Lines 91-93 Intervention terms
  • Lines 97-121 Cultural competence in its many forms and targets
KQ3 Study Filters, Disability Population Terms, and Cultural Competence Terms
#Searches
1meta analysis as topic/
2meta-analy$.tw.
3metaanaly$.tw.
4meta-analysis/
5(systematic adj (review$1 or overview$1)).tw.
6exp Review Literature as Topic/
7or/1-6
8cochrane.ab.
9embase.ab.
10(psychlit or psyclit).ab.
11(psychinfo or psycinfo).ab.
12or/8-11
13reference list$.ab.
14bibliograph$.ab.
15hand search.ab.
16relevant journals.ab.
17manual search$.ab.
18or/13-17
19selection criteria.ab.
20(data adj2 (extract* or abstract*)).ab.
2119 or 20
22review/
2321 and 22
24Comment/
25Letter/
26editorial/
27animal/
28human/
2927 not (28 and 27)
30or/24-26,29
317 or 12 or 18 or 23
3231 not 30
33randomized controlled trials as topic/
34randomized controlled trial/
35random allocation/
36double blind method/
37single blind method/
38clinical trial/
39clinical trial, phase i.pt.
40clinical trial, phase ii.pt.
41clinical trial, phase iii.pt.
42clinical trial, phase iv.pt.
43controlled clinical trial.pt.
44randomized controlled trial.pt.
45multicenter study.pt.
46clinical trial.pt.
47exp clinical trials as topic/
48or/33-47
49(clinical adj trial$).tw.
50((singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)).tw.
51placebos/
52placebo$.tw.
53randomly allocated.tw.
54(allocated adj2 random$).tw.
55or/49-54
5648 or 55
57case report.tw.
58letter/
59historical article/
60or/57-59
6156 not 60
62exp cohort studies/ or comparative study/ or follow-up studies/ or prospective studies/ or cohort.mp. or compared.mp. or groups.mp. or multivariate.mp.
63cohort$.tw.
64controlled clinical trial.pt.
65epidemiological methods/
66limit 65 to yr=1971-1983
67or/62-64,66
68exp disabled person/ or (amputee$ or disabled person$ or disabled child$ or disab$ or disabled people or mentally disabled person$ or mentally disabled people or mentally ill person$ or mentally ill people or visually impaired person$ or visually impaired people or hearing impaired person$ or hearing impaired people).mp.
69exp mental disorders diagnosed in childhood/ or (Asperger Syndrome or Aperger$ or Autism or Autistic or Autistic Disorde$ or learning disabil$ or learning disorder$ or developmental disability$ or Attention Deficit Disorder$ or Attention Deficit Disorder with Hyperactivity or behavior$ disorder$ or conduct disorder$ or dyslexia or affective Disorder$ or mood disorder$ or depress$ or depress$ disorder$ or personality disorder$).mp.
70exp cognition disorders/ or (cognit$ disord$ or cognit$ disabil$ or Mild Cognitive Impairment$ or Huntington$ or cognitive$ impair$).mp.
71exp intellectual disability/ or (intellectual disab$ or Down Syndrome or mental$ retard$ or Fragile X or Rett Syndrome or Prader-Willi Syndrome or Williams Syndrome).mp.
72exp "Activities of Daily Living"/ or (activit$ of daily living or functional limitation$ or activity limitation$ or participation limitation$).mp.
73Mobility limitation/ or (mobility limitation$ or mobility impairment$).mp.
74Dependent ambulation/ or dependent ambulation.mp.
75Paraplegia/ or paraplegia.mp.
76Quadriplegia/ or quadriplegia.mp.
77Hearing loss/ or (hearing loss or hearing impair$ or deaf$).mp.
78Vision disorders/ or (blind$ or vis$ impair$).mp.
79exp self-help devices/ or (assist$ techn$ or Commun$ Aid$ or commun$ device$ or Wheelchair$).mp.
80Mental disorders/ or (mental disorder$ or psychiatric disabilit$ or mental health disabilit$ or mental health impairment$).mp.
81or/68-80
8232 and 81
8361 and 81
8467 and 81
85limit 82 to yr="1990-Current"
86limit 83 to yr="1990-Current"
87limit 84 to yr="1990-Current"
8885 not (86 or 87)
8986 not (85 or 87)
9087 not (85 or 86)
91intervention*.ti,ab.
92program*.ti,ab.
9391 or 92
9488 and 93
9589 and 93
9690 and 93
97culture/ or cross-cultural comparison/ or cultural characteristics/ or cultural competency/ or cultural diversity/
98multilingualism/ or language/
99((cultur* or linguistic* or language*) adj3 (competenc* or understanding or knowledg* or expertise or skill* or sensitiv* or aware* or appropriate* or acceptab* or safe* or humility or service* or communicat* or barrier* or divers* or comparison* or identity or specific or background* or value* or belief*)).tw.
100(intercultural* or inter-cultural or transcultural* or trans-cultural or cross-cultural or crosscultural or multicultural* or multicultural* or bicultural or bi-cultural or multilingual* or multi-lingual* or bilingual or bi-lingual).tw.
101transcultural nursing/
102minority groups/ or minority Health/
103exp teaching/
104exp health personnel/ed
105exp teaching materials/
106exp education/
107((education* or teaching or learning or elearning or instruction* or training or skills or didactic or pedagogic* or online or online or web* or internet or cd-rom* or dvd or multimedia or multi-media or computer*) adj2 (intervention* or session* or course* or program* or activit* or presentation* or round* or material* or package* or module* or demonstration* or method* or process*)).tw.
108(inservice or in service or workshop* or (discussion adj1 group*) or lectur* or seminar* or (short adj2 course*) or role play* or immersion or mentor* or lifelong learning or life long learning).tw.
109((staff or professional or workforce or work force) adj (development or training)).tw.
110((medical or continuing or residency or distance) adj2 education).tw.
111(curriculum or curricul* intervent*).tw.
112((cultural* or transcultural* or multicultural* or intercultural* or bicultural*) adj2 (education or train* or teach* or learn* or instruct* or coach* or skills or content*)).tw.
113health education/ or health promotion/ or primary prevention/
114health services accessibility/ or healthcare disparities/
115"Attitude of Health Personnel"/
116Community-Based Participatory Research/
117Medicine, Traditional/
118Health Communication/
119community health workers/
120consumer participation/ or patient participation/
121or/97-120
12294 and 121
12395 and 121
12496 and 121

KQ4 Study Filters, Racial Ethnic Population Terms, and Cultural Competence

  • Lines 1-32 Filter for systematic reviews
  • Lines 33-61 Filter for controlled trials
  • Lines 62-67 Filter for observational studies
  • Lines 68-73 Population terms
  • Lines 83-85 Intervention terms
  • Lines 89-113 Cultural competence in its many forms and targets
  • Line 118 To further restrict observational studies
KQ4 Study Filters, Racial Ethnic Population Terms, and Cultural Competence
#Searches
1meta analysis as topic/
2meta-analy$.tw.
3metaanaly$.tw.
4meta-analysis/
5(systematic adj (review$1 or overview$1)).tw.
6exp Review Literature as Topic/
7or/1-6
8cochrane.ab.
9embase.ab.
10(psychlit or psyclit).ab.
11(psychinfo or psycinfo).ab.
12or/8-11
13reference list$.ab.
14bibliograph$.ab.
15hand search.ab.
16relevant journals.ab.
17manual search$.ab.
18or/13-17
19selection criteria.ab.
20(data adj2 (extract* or abstract*)).ab.
2119 or 20
22review/
2321 and 22
24Comment/
25Letter/
26editorial/
27animal/
28human/
2927 not (28 and 27)
30or/24-26,29
317 or 12 or 18 or 23
3231 not 30
33randomized controlled trials as topic/
34randomized controlled trial/
35random allocation/
36double blind method/
37single blind method/
38clinical trial/
39clinical trial, phase i.pt.
40clinical trial, phase ii.pt.
41clinical trial, phase iii.pt.
42clinical trial, phase iv.pt.
43controlled clinical trial.pt.
44randomized controlled trial.pt.
45multicenter study.pt.
46clinical trial.pt.
47exp clinical trials as topic/
48or/33-47
49(clinical adj trial$).tw.
50((singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)).tw.
51placebos/
52placebo$.tw.
53randomly allocated.tw.
54(allocated adj2 random$).tw.
55or/49-54
5648 or 55
57case report.tw.
58letter/
59historical article/
60or/57-59
6156 not 60
62exp cohort studies/ or comparative study/ or follow-up studies/ or prospective studies/ or cohort.mp. or compared.mp. or groups.mp. or multivariate.mp.
63cohort$.tw.
64controlled clinical trial.pt.
65epidemiological methods/
66limit 65 to yr=1971-1983
67or/62-64,66
68population groups/ or african continental ancestry group/ or african americans/ or indians, north american/ or inuits/ or asian americans/ or oceanic ancestry group/ or ethnic groups/ or arabs/ or hispanic americans/ or mexican americans/
69"Emigration and Immigration"/ or "Emigrants and Immigrants"/ or "Transients and Migrants"/ or refugees/
70race relations/ or racism/
71(immigrant* or migrant* or refugee* or (displaced and (people or person*)) or ("foreign born" or "non us born" or "non-us born") or undocumented or second language* or ((language or english) and proficien*) or interpreter* or "minority group*" or "ethnic group*" or "urban health" or "urban population" or "inner city" or ethnic* or race or racial or minorit* or urban or inner-city or multiethnic).tw.
72(non-english or hispanic* or latin* or ((african or black or asian or native or mexican) adj american*) or inuit* or islander*).tw.
73or/68-72
7432 and 73
7561 and 73
7667 and 73
77limit 74 to yr="1990-Current"
78limit 75 to yr="1990-Current"
79limit 76 to yr="1990-Current"
8077 not (78 or 79)
8178 not (77 or 79)
8279 not (77 or 78)
83intervention*.ti,ab.
84program*.ti,ab.
8583 or 84
8680 and 85
8781 and 85
8882 and 85
89culture/ or cross-cultural comparison/ or cultural characteristics/ or cultural competency/ or cultural diversity/
90multilingualism/ or language/
91((cultur* or linguistic* or language*) adj3 (competenc* or understanding or knowledg* or expertise or skill* or sensitiv* or aware* or appropriate* or acceptab* or safe* or humility or service* or communicat* or barrier* or divers* or comparison* or identity or specific or background* or value* or belief*)).tw.
92(intercultural* or inter-cultural or transcultural* or trans-cultural or cross-cultural or crosscultural or multicultural* or multicultural* or bicultural or bi-cultural or multilingual* or multi-lingual* or bilingual or bi-lingual).tw.
93transcultural nursing/
94minority groups/ or minority Health/
95exp teaching/
96exp health personnel/ed
97exp teaching materials/
98exp education/
99((education* or teaching or learning or elearning or instruction* or training or skills or didactic or pedagogic* or online or online or web* or internet or cd-rom* or dvd or multimedia or multi-media or computer*) adj2 (intervention* or session* or course* or program* or activit* or presentation* or round* or material* or package* or module* or demonstration* or method* or process*)).tw.
100(inservice or in service or workshop* or (discussion adj1 group*) or lectur* or seminar* or (short adj2 course*) or role play* or immersion or mentor* or lifelong learning or life long learning).tw.
101((staff or professional or workforce or work force) adj (development or training)).tw.
102((medical or continuing or residency or distance) adj2 education).tw.
103(curriculum or curricul* intervent*).tw.
104((cultural* or transcultural* or multicultural* or intercultural* or bicultural*) adj2 (education or train* or teach* or learn* or instruct* or coach* or skills or content*)).tw.
105health education/ or health promotion/ or primary prevention/
106health services accessibility/ or healthcare disparities/
107"Attitude of Health Personnel"/
108Community-Based Participatory Research/
109Medicine, Traditional/
110Health Communication/
111community health workers/
112consumer participation/ or patient participation/
113or/89-112
11486 and 113
11587 and 113
11688 and 113
117or/89-94
118Healthcare Disparities/
119117 or 118
120116 and 119
Appendix B. Risk of Bias Assessment Form for Observational Studies
(Author_______; Year_______; PMID_______; Reviewer_______)
#QuestionResponse*Criteria*Justification
*Internal Validity
1Is the study design prospective, retrospective, or mixed?ProspectiveOutcome has not occurred at the time the study is initiated and information is collected over time to assess relationships with the outcome.
MixedStudies in which one group is studied prospectively and the other retrospectively.
RetrospectiveAnalyzes data from past records.
2Are inclusion/exclusion criteria clearly stated?Yes
PartiallySome, but not all, criteria stated or some not clearly stated.
No
3Are baseline characteristics measured using valid and reliable measures and equivalent in both groups?Yes
No
UncertainCould not be ascertained.
4Is the level of detail describing the intervention adequate?YesIntervention described included adequate service details
PartiallySome of the above features.
NoNone of the above features.
5Is the selection of the comparison group appropriate?YesConsidering patient characteristics
6Did researchers isolate the impact from a concurrent intervention or an unintended exposure that might bias results?YesAccounted for concurrent informal care
Partially
No
7Any attempt to balance the allocation between the groups (e.g. stratification, matching, propensity scores)?Yes(if yes, what was used?)
No
UncertainCould not be ascertained.
8Were outcomes assessors blinded?Who were outcome assessors?
9Are outcomes assessed using valid and reliable measures, implemented consistently across all study participants?YesMeasure valid and reliable (i.e. objective measures, well validated scale, provider report); and equivalent across groups.
PartiallySome of the above features
(partially validated scale)
NoNone of the above features (self-report, scales with lower validity, reliability); not equivalent across groups
UncertainCould not be ascertained.
10Is the length of follow-up the same for all groups?Yes
No
UncertainCould not be ascertained.
11Did attrition result in a difference in group characteristics between baseline and follow-up?Yes(measurement period of interest if repeated measures)
No
UncertainCould not be ascertained (i.e. retrospective designs where eligible at baseline could not be determined)
12If baseline characteristics are not similar, does the analysis control for baseline differences between groups?Yes
No
UncertainCould not be ascertained (i.e. retrospective designs where eligible at baseline could not be determined)
13Are confounding and/or effect modifying variables assessed using valid and reliable measures across all study participants?Yes
No
UncertainCould not be ascertained (i.e. retrospective designs where eligible at baseline could not be determined)
NANo confounders or effect modifiers included in the study.
14Were the important confounding and effect modifying variables taken into account in the design and/or analysis (e.g. through matching, stratification, interaction terms, multivariate analysis, or other statistical adjustment)?Yes
PartiallySome variables taken into account or adjustment achieved to some extent.
NoNot accounted for or not identified.
UncertainCould not be ascertained
15Are the statistical methods used to assess the primary outcomes appropriate to the data?YesStatistical techniques used must be appropriate to the data.
Partially
No
UncertainCould not be ascertained
16Are reports of the study free of suggestion of selective outcome reporting?Yes
NoNot all prespecified outcomes reported, subscales not prespecified reported, outcomes reported incompletely.
UncertainCould not be ascertained.
17Funding source identifiedNoIndustry, government, university, Foundation (funded by what money source?)
YesWho provided funding?
Uncertain
Overall Risk of Bias AssessmentLowResults are believable taking study limitations into consideration
ModerateResults are probably believable taking study limitations into consideration
HighResults are uncertain taking study limitations into consideration

FAQs

How cultural competency can help reduce health disparities? ›

Enhancing cultural competency among health care providers and providing culturally appropriate services can improve communication, access to health care, and eventually health outcomes.

Can cultural competency reduce racial and ethnic health disparities? ›

Cultural competency techniques potentially could change both clinician and patient behavior by improving communication, increasing trust, creating a greater knowledge of the differences among racial and ethnic groups in epidemiology and treatment efficacy, and expanding understanding of patients' cultural behaviors and ...

What are 3 examples of strategies to help improve culturally competent care? ›

WHAT IS CULTURAL COMPETENCE IN HEALTH CARE?
  • Provide interpreter services.
  • Recruit and retain minority staff.
  • Provide training to increase cultural awareness, knowledge, and skills.
  • Coordinate with traditional healers.
  • Use community health workers.
  • Incorporate culture-specific attitudes and values into health promotion tools.

Why is cultural competency important when addressing health problems within a specific population? ›

Cultural competence improves communication, which keeps patients safer. Clear communication allows healthcare providers to collect accurate medical information. It also encourages active dialogues in which patients and providers can ask questions, correct misunderstandings, and build trust.

What is the importance of cultural competence in healthcare? ›

Importance of Cultural Competence in Nursing Care

A strong background and knowledge of cultural competence prevents professional health caregivers from possessing stereotypes and being myopic in their thoughts. It also helps them offer the best service to all, regardless of their social status or belief.

How can cultural competence improve health equity? ›

Research has demonstrated that cultural competence training can improve health care provider knowledge, understanding, and skills in treating patients from diverse socioeconomic, cultural, and linguistic backgrounds.

How does cultural competence affect health disparities? ›

Culturally competent care is seen as foundational for reducing disparities. Culturally competent care respects diversity as well as the cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.

What are 4 strategies that support cultural competence? ›

How do I become culturally competent?
  • Learn about yourself. Get started by exploring your own historical roots, beliefs and values, says Robert C. ...
  • Learn about different cultures. ...
  • Interact with diverse groups. ...
  • Attend diversity-focused conferences. ...
  • Lobby your department.

Why is it important to have cultural competence? ›

Cultural competence is important because without it, our opportunity to build those relationships is impossible. Instead, we'll co-exist with people we don't understand, thereby creating a higher risk for misunderstandings, hurt feelings, and bias—things that can all be avoided.

What are the five principles of cultural competence? ›

Have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity and the cultural contexts of communities they serve.

What are the 6 stages of cultural competence? ›

The Cross framework emphasizes that the process of achieving cultural competency occurs along a continuum and sets forth six stages including: 1) cultural destructiveness, 2) cultural incapacity, 3) cultural blindness, 4) cultural pre-competence, 5) cultural competency and 6) cultural proficiency.

What are five points of cultural diversity in healthcare? ›

In her model, Campinha-Bacote describes five interrelated concepts: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill, (4) cultural encounters, and (5) cultural desire.

What does cultural competence mean for healthcare providers? ›

Cultural competency in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of health care delivery to meet patients' social, cultural and linguistic needs.

What is an essential component of cultural competence for healthcare workers? ›

Showing respect for your patients' cultural, spiritual, and psychosocial values demonstrates cultural competency. 1 Cultural competency enables healthcare workers to understand their patient's expectations about the care, treatment, and services they receive.

What are some examples of cultural barriers in healthcare? ›

  • Reluctance to provide health services. One cultural issue that a number of people with disability raised was providers' reluctance to provide healthcare services for PWD. ...
  • Disrespect. ...
  • Denial of disability. ...
  • Disproportionate expectations. ...
  • Shame. ...
  • Little attention to the culture of disability. ...
  • Misconception. ...
  • Discrimination.
3 Sept 2017

How do you provide culturally competent care? ›

7 Steps Nurses Can Take to Provide Culturally Sensitive Care
  1. Awareness. As with any social issue, the first step is awareness. ...
  2. Avoid Making Assumptions. ...
  3. Learn About Other Cultures. ...
  4. Build Trust and Rapport. ...
  5. Overcome Language Barriers. ...
  6. Educate Patients About Medical Practices. ...
  7. Practice Active Listening.
15 Jan 2022

What are the four components of cultural competence? ›

Cultural competence has four major components: awareness, attitude, knowledge, and skills.

Why is cultural competence and cultural humility important in public health and healthcare? ›

Cultural Humility and Cultural Competency

Keeping an open mind allows individuals to mitigate unconscious biases that can negatively impact our daily interactions and have shown to contribute to health care disparities.

What is cultural disparity in healthcare? ›

Cultural disparities in healthcare happen within a mix of influences, including cultural incompetency, social inequality, the structure and function of communities of care, and the social conditions that undermine or enhance well-being.

How does culture impact healthcare? ›

The influence of culture on health is vast. It affects perceptions of health, illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer.

How can social work improve cultural competence? ›

Tips for developing culturally competent social work practice. Spend some time getting to know the service user, do not rush meetings and interventions. Be continually aware of the social work values you have signed up to as a social worker. Be self-aware – remember your personal cultural values and beliefs.

What is the meaning of cultural competence? ›

"Cultural competency means being aware of your own cultural beliefs and values and how these may be different from other cultures—including being able to learn about and honor the different cultures of those you work with."

Which is one of the most important elements in regards to cultural competence? ›

Overall, cultural competence has three important components: active listening, demonstrating empathy, and effective engagement.

What is cultural competence and how is it developed? ›

Developing cultural competence helps us understand, communicate with, and effectively interact with people across cultures. It gives us the ability to compare different cultures with our own and better understand the differences. Unconsciously, we bring our own cultural frame of interpretation to any situation.

How could you develop or improve your social and cultural awareness provide at least three strategies? ›

SEVEN PRACTICES YOU CAN IMPLEMENT TO INCREASE CULTURAL AWARENESS IN THE WORKPLACE
  • Get training for global citizenship. ...
  • Bridge the culture gap with good communication skills. ...
  • Practice good manners. ...
  • Celebrate traditional holidays, festivals, and food. ...
  • Observe and listen to foreign customers and colleagues.
22 Sept 2017

What is a top recommendation for improving cross cultural competency? ›

1. Attend Diversity-Focused Training or Conferences. Receive formal education and training on diversity-related studies. Aside from that, practice issues by gaining knowledge regarding new research findings and attending diversity training and symposiums.

Is cultural competence effective? ›

Several studies have demonstrated that cultural competence improves patient-provider communication, which promotes adherence to established care plans and improves patient satisfaction and health outcomes.

How can cultural differences affect patient care? ›

Cultural beliefs can affect how a patient will seek care and from whom, how he or she will manage self-care, how he will make health choices, and how she might respond to a specific therapy. Cultural issues play a key role in compliance, which is a person's willingness to adhere to the doctor's recommendations.

What is a major reason for becoming more culturally competent? ›

Cultural competence is important for a few reasons. The first major reason is because we live in a diverse society. We are diverse with respect to race/ethnicity, social class, gender, sexual orientation, ability, age and religion/spirituality. It should not be assumed that any perspective is better than the other.

How can we improve cultural awareness? ›

Use these tips from the American Psychological Association to be more culturally aware:
  1. Think beyond race and ethnicity. A person's culture is shaped by more than the color of their skin or the way that they dress. ...
  2. Learn by asking. ...
  3. Make local connections. ...
  4. Pay attention to non-verbal behaviors. ...
  5. Exchange stories.
22 Jul 2019

What is the first step to cultural competence? ›

Developing cultural awareness is often the first step in working with young people and families. This involves learning about the cultural norms, values, beliefs and practices of the CLD communities that your agency services. Workers should find out about the: languages spoken within these communities.

What is another word for cultural competence? ›

Cultural competence, also known as intercultural competence, is a range of cognitive, affective, and behavioural skills that lead to effective and appropriate communication with people of other cultures.

Which is the most important aspect of cultural competence in nursing? ›

The most important aspect of providing culturally competent care is exhibited through what action by the nurse? Assessing and listening to each patient's customs and beliefs is the most important way to provide culturally congruent and patient-centered care.

Why cultural competence is important in nursing? ›

In simplest terms, a group's culture is its shared beliefs, language, social customs, and other behaviors. Cultural competence in nursing tailors healthcare to fit a patient's unique cultural background. Cultural competence in nursing is essential because a patient's culture can affect how they: Describe their symptoms.

Why is cultural competence important in the workplace? ›

Cultural competence in the workplace can help managers and employees better communicate and coordinate with co-workers and clients. This can increase engagement and productivity.

How do you develop culturally competent communication? ›

Being aware of your own culture opens you to understanding and being more sensitive to the cultures of others.
  1. communicating in a. culturally appropriate way.
  2. Speak clearly and concisely.
  3. Check for understanding.
  4. Be aware of non-verbal. ...
  5. Be aware of the impact of culture.
  6. You are communicating. ...
  7. All cultures are equal.

What are the stages of achieving cultural competence? ›

Individuals and organizations interacting and working with various cultural and ethnic backgrounds can achieve cultural competency by going through a three-stage development process: developing cultural awareness, acquiring cultural knowledge, and enhancing cross-cultural skills.

How can cultural barriers to health care be overcome? ›

Interpreting Nonverbal Cues
  1. Ask questions that demonstrate respect and concern.
  2. Ask questions that help reveal the patient's understanding of the health issue at hand.
  3. Explain their own perceptions.
  4. Acknowledge differences in perceptions.
  5. Begin to negotiate treatment plans.

How do you promote diversity in health and social care? ›

Provide person-centered care and work in a non-judgemental manner. Employees should be encouraged to value diversity and respect the attributes that make people different. Care plans should be personalised to reflect the likes, dislikes, personal history and beliefs of each individual.

How can diversity be improved in healthcare? ›

How to Promote Diversity in Healthcare
  1. Create a Welcoming Environment. Foster an environment of inclusiveness in every area possible. ...
  2. Address Issues of Bias Quickly and Openly. ...
  3. Encourage Diverse Applicants. ...
  4. Diversity for More Than Diversity's Sake. ...
  5. Listen.
1 Jun 2022

How does being culturally competent improve healthcare? ›

Improved Patient Outcomes

Cultural competence improves communication, which keeps patients safer. Clear communication allows healthcare providers to collect accurate medical information. It also encourages active dialogues in which patients and providers can ask questions, correct misunderstandings, and build trust.

What is the importance of cultural competence in healthcare? ›

A person's cultural affiliations can impact everything from where and how they seek care to how they describe symptoms and whether they follow care recommendations. A culturally competent healthcare system is one able to provide care to patients with diverse values, beliefs, and behaviors.

Why is competence important in healthcare? ›

Ultimately, managing competency in a healthcare organization is essential because improvements in employee competencies improve outcomes. Employees are more satisfied when they work with competent peers. Patients are more satisfied when they perceive their care came from well-qualified and competent staff.

What are 4 strategies that support cultural competence? ›

How do I become culturally competent?
  • Learn about yourself. Get started by exploring your own historical roots, beliefs and values, says Robert C. ...
  • Learn about different cultures. ...
  • Interact with diverse groups. ...
  • Attend diversity-focused conferences. ...
  • Lobby your department.

How do you incorporate cultural competence in nursing? ›

Here are 5 ways to help you provide culturally competent nursing care.
  1. Perform a cultural competence self-assessment. ...
  2. Obtain a certificate in cultural competence. ...
  3. Improve communication and language barriers. ...
  4. Directly engage in cross-cultural interactions with patients. ...
  5. Participate in online chats and networks.
24 May 2018

What does it mean to be culturally competent in nursing? ›

Culturally competent care includes knowledge, attitudes, and skills that support caring for people across different languages and cultures. 1. Culture influences not only health practices but also how the healthcare provider and the patient perceive illness.

What is the link between health disparities and cultural competence? ›

Culturally competent care is seen as foundational for reducing disparities. Culturally competent care respects diversity as well as the cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors.

Why is it important to have cultural competence? ›

Cultural competence is important because without it, our opportunity to build those relationships is impossible. Instead, we'll co-exist with people we don't understand, thereby creating a higher risk for misunderstandings, hurt feelings, and bias—things that can all be avoided.

Why is it important to be culturally competent in nursing? ›

Cultural competence in nursing is essential because a patient's culture can affect how they: Describe their symptoms. Approach care options. Implement treatment plans.

What are 4 strategies that support cultural competence? ›

How do I become culturally competent?
  • Learn about yourself. Get started by exploring your own historical roots, beliefs and values, says Robert C. ...
  • Learn about different cultures. ...
  • Interact with diverse groups. ...
  • Attend diversity-focused conferences. ...
  • Lobby your department.

What are 5 Barriers to cultural competence? ›

This is a result of the fact that people from different cultural groups approach challenges and problems in different ways.
...
Five causes of cultural barriers
  • Language. ...
  • Stereotypes and prejudices. ...
  • Signs and symbols. ...
  • Behaviors and belief. ...
  • “Us” versus “them” (ethnocentrism)

What are the five principles of cultural competence? ›

Have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity and the cultural contexts of communities they serve.

What does it mean to provide culturally competent health care? ›

Cultural competency in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of health care delivery to meet patients' social, cultural and linguistic needs.

What are the 4 elements of cultural competence? ›

Cultural competence is comprised of four components: (a) Awareness of one's own cultural worldview, (b) Attitude towards cultural differences, (c) Knowledge of different cultural practices and worldviews, and; (d) Cross cultural Skills.

What are some examples of cultural barriers in healthcare? ›

  • Reluctance to provide health services. One cultural issue that a number of people with disability raised was providers' reluctance to provide healthcare services for PWD. ...
  • Disrespect. ...
  • Denial of disability. ...
  • Disproportionate expectations. ...
  • Shame. ...
  • Little attention to the culture of disability. ...
  • Misconception. ...
  • Discrimination.
3 Sept 2017

How do you provide culturally competent care? ›

7 Steps Nurses Can Take to Provide Culturally Sensitive Care
  1. Awareness. As with any social issue, the first step is awareness. ...
  2. Avoid Making Assumptions. ...
  3. Learn About Other Cultures. ...
  4. Build Trust and Rapport. ...
  5. Overcome Language Barriers. ...
  6. Educate Patients About Medical Practices. ...
  7. Practice Active Listening.
15 Jan 2022

How can nurses develop cultural competence? ›

So when becoming a culturally competent nurse, remember: KNOWLEDGE: Acquire a knowledge base of cultures in your service area, especially in relation to healthcare practices and beliefs. ATTITUDE: Avoid making stereotypical assumptions about your patients' culture; become aware of your own biases and prejudices.

How do cultural differences affect healthcare? ›

Culture influences healthcare at all levels, including communications and interactions with doctors and nurses, health disparities, health care outcomes, and even the illness experience itself. People in some cultures believe illness is the will of a higher power, and may be more reluctant to receive health care.

What are the 6 stages of cultural competence? ›

The Cross framework emphasizes that the process of achieving cultural competency occurs along a continuum and sets forth six stages including: 1) cultural destructiveness, 2) cultural incapacity, 3) cultural blindness, 4) cultural pre-competence, 5) cultural competency and 6) cultural proficiency.

How can social work improve cultural competence? ›

Tips for developing culturally competent social work practice. Spend some time getting to know the service user, do not rush meetings and interventions. Be continually aware of the social work values you have signed up to as a social worker. Be self-aware – remember your personal cultural values and beliefs.

What is cultural competence and how is it developed? ›

Developing cultural competence helps us understand, communicate with, and effectively interact with people across cultures. It gives us the ability to compare different cultures with our own and better understand the differences. Unconsciously, we bring our own cultural frame of interpretation to any situation.

Videos

1. Cultural Competence and Diversity
(UCSF Dept. of Psychiatry and Behavioral Sciences)
2. 5 Slides: A focus on developing cultural competency in health care
(State of Reform)
3. Cultural Competence and Quality of Care
(University of California Television (UCTV))
4. Increasing SLPs’ Cultural Competence ToT Dec 2020
(VEIPD Videos)
5. NACNR- 1/2017 Future Research Priorities for Minority Health and Health Disparities Research
(NINRnews)
6. Webinar | State Approaches to Addressing Health Disparities
(NCSLorg)

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