Aysegul Gozu

Cultural competence: A systematic review of health care provider educational interventions

Objective:We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals. Design:This was a systematic literature review and analysis. Methods:We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria. Main Outcome Measures:We sought evidence of the effectiveness and costs of cultural competence training of health professionals. Results:Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs). Conclusions:Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective.

Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions

BackgroundDespite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities.MethodsWe performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities.ResultsTwenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data.ConclusionThere are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.

A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals

Purpose To systematically examine the methodological rigor of studies using cultural competence training as a strategy to improve minority health care quality. To the authors’ knowledge, no prior studies of this type have been conducted. Method As part of a systematic review, the authors appraised the methodological rigor of studies published in English from 1980 to 2003 that evaluate cultural competence training, and determined whether selected study characteristics were associated with better study quality as defined by five domains (representativeness, intervention description, bias and confounding, outcome assessment, and analytic approach). Results Among 64 eligible articles, most studies (no. = 59) were published recently (1990–2003) in education (no. = 26) and nursing (no. = 14) journals. Targeted learners were mostly nurses (no. = 32) and physicians (no. = 19). Study designs included randomized or concurrent controlled trials (no. = 10), pretest/posttest (no. = 22), posttest only (no. = 27), and qualitative evaluation (no. = 5). Curricular content, teaching strategies, and evaluation methods varied. Most studies reported provider outcomes. Twenty-one articles adequately described provider representativeness, 21 completely described curricular interventions, eight had adequate comparison groups, 27 used objective evaluations, three blinded outcome assessors, 14 reported the number or reason for noninclusion of data, and 15 reported magnitude differences and variability indexes. Studies targeted at physicians more often described providers and interventions. Most trials completely described targeted providers, had adequate comparison groups, and reported objective evaluations. Study quality did not differ over time, by journal type, or by the presence or absence of reported funding. Conclusions Lack of methodological rigor limits the evidence for the impact of cultural competence training on minority health care quality. More attention should be paid to the proper design, evaluation, and reporting of these training programs.

The Role of Cultural Diversity Climate in Recruitment, Promotion, and Retention of Faculty in Academic Medicine

BACKGROUND: Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals.OBJECTIVES: To explore the perceptions of physician faculty regarding the following: (1) the institution’s cultural diversity climate and (2) facilitators and barriers to success and professional satisfaction in academic medicine within this context.DESIGN: Qualitative study using focus groups and semi-structured interviews.PARTICIPANTS: Nontenured physicians in the tenure track at the Johns Hopkins University School of Medicine.APPROACH: Focus groups and interviews were audio-taped, transcribed verbatim, and reviewed for thematic content in a 3-stage independent review/adjudication process.RESULTS: Study participants included 29 faculty representing 9 clinical departments, 4 career tracks, and 4 ethnic groups. In defining cultural diversity, faculty noted visible (race/ethnicity, foreign-born status, gender) and invisible (religion, sexual orientation) dimensions. They believe visible dimensions provoke bias and cumulative advantages or disadvantages in the workplace. Minority and foreign-born faculty report ethnicity-based disparities in recruitment and subtle manifestations of bias in the promotion process. Minority and majority faculty agree that ethnic differences in prior educational opportunities lead to disparities in exposure to career options, and qualifications for and subsequent recruitment to training programs and faculty positions. Minority faculty also describe structural barriers (poor retention efforts, lack of mentorship) that hinder their success and professional satisfaction after recruitment. To effectively manage the diversity climate, our faculty recommended 4 strategies for improving the psychological climate and structural diversity of the institution.CONCLUSIONS: Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution’s diversity climate.

Self-Administered Instruments to Measure Cultural Competence of Health Professionals: A Systematic Review

Background: Tools that measure knowledge, attitudes, and skills reflecting cultural competence of health professionals have not been comprehensively identified, described, or critiqued. Summary: We systematically reviewed English-language articles published from 1980 through June 2003 that evaluated the effectiveness of cultural competence curricula targeted at health professionals by using at least one self-administered tool. We abstracted information about targeted providers, evaluation methods, curricular content, and the psychometric properties of each tool. We included 45 articles in our review. A total of 45 unique instruments (32 learner self-assessments, 13 written exams) were used in the 45 articles. One third (15/45) of the tools had demonstrated either validity or reliability, and only 13% (6/45) had demonstrated both reliability and validity. Conclusions: Most studies of cultural competence training used self-administered tools that have not been validated. The results of cultural competence training could be interpreted more accurately if validated tools were used.

Professional experiences of international medical graduates practicing primary care in the United States.

BackgroundInternational medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited.ObjectiveTo characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US.DesignQualitative study based on in-depth in-person interviews.ParticipantsPurposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut.ApproachA standardized interview guide was used to explore professional experiences of IMGs.Key ResultsFour recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of “the deal”; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace.ConclusionsOur data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs’ experiences may also improve the experiences of an increasingly diverse healthcare workforce.

A ten-month program in curriculum development for medical educators: 16 years of experience.

BACKGROUNDDespite increased demand for new curricula in medical education, most academic medical centers have few faculty with training in curriculum development.OBJECTIVETo describe and evaluate a longitudinal mentored faculty development program in curriculum development.DESIGNA 10-month curriculum development program operating one half-day per week of each academic year from 1987 through 2003. The program was designed to provide participants with the knowledge, attitudes, skills, and experience to design, implement, evaluate, and disseminate curricula in medical education using a 6-step model.PARTICIPANTSOne-hundred thirty-eight faculty and fellows from Johns Hopkins and other institutions and 63 matched nonparticipants.MEASUREMENTSPre- and post-surveys from participants and nonparticipants assessed skills in curriculum development, implementation, and evaluation, as well as enjoyment in curriculum development and evaluation. Participants rated program quality, educational methods, and facilitation in a post-program survey.RESULTSSixty-four curricula were produced addressing gaps in undergraduate, graduate, or postgraduate medical education. At least 54 curricula (84%) were implemented. Participant self-reported skills in curricular development, implementation, and evaluation improved from baseline (p < .0001), whereas no improvement occurred in the comparison group. In multivariable analyses, participants rated their skills and enjoyment at the end of the program significantly higher than nonparticipants (all p < .05). Eighty percent of participants felt that they would use the 6-step model again, and 80% would recommend the program highly to others.CONCLUSIONSThis model for training in curriculum development has long-term sustainability and is associated with participant satisfaction, improvement in self-rated skills, and implementation of curricula on important topics.

Long‐term follow‐up of a 10‐month programme in curriculum development for medical educators: a cohort study

Context  There is an ongoing need for curriculum development (CD) in medical education. However, only a minority of medical teaching institutions provide faculty development in CD. This study evaluates the long‐term impact of a longitudinal programme in curriculum development.

Clinicians' Perceptions About How They Are Valued by the Academic Medical Center

p a w m p f Academic health centers have multiple distinct yet interrelated missions related to advancing research and discovery, educating the next generation of physicians, and caring for patients with expertise and humanism. The reverence directed toward accomplishment in research at our academic health center exceeds the value directed toward clinical and educational successes, as reflected in both the culture and the promotion processes. Because promotion decisions and academic rank are heavily influenced by research success and not clinical accomplishments, distinction in the clinical care of patients is thought to be “under-rewarded and taken for granted.” Some academic health centers have established multiple tracks for promotion in an effort to balance the appreciation for all 3 parts of the tripartite mission, but even at those academic health centers, clinicians or clinician-educators who are part of these alternate tracks may feel as though they are members of a “second class.” Clinical care is critical to an academic health center’s bottom line and financial viability, generating ap-

Fit for purpose: perspectives on rapid reviews from end-user interviews

BackgroundThere is increasing demand for rapid reviews and timely evidence synthesis. The goal of this project was to understand end-user perspectives on the utility and limitations of rapid products including evidence inventories, rapid responses, and rapid reviews.MethodsInterviews were conducted with key informants representing: guideline developers (n = 3), health care providers/health system organizations (n = 3), research funders (n = 1), and payers/health insurers (n = 1). We elicited perspectives on important characteristics of systematic reviews, acceptable methods to streamline reviews, and uses of rapid products. We analyzed content of the interview transcripts and identified themes and subthemes.ResultsKey informants identified the following as critical features of evidence reviews: (1) originating from a reliable source (i.e., conducted by experienced reviewers from an established research organization), (2) addressing clinically relevant questions, and (3) trusted relationship between the user and producer. Key informants expressed strong preference for the following review methods and characteristics: use of evidence tables, quality rating of studies, assessments of total evidence quality/strength, and use of summary tables for results and conclusions. Most acceptable trade-offs to increase efficiencies were limiting the literature search (e.g., limiting search dates or language) and performing single screening of citations and full texts for relevance. Key informants perceived rapid products (particularly evidence inventories and rapid responses) as useful interim products to inform downstream investigation (e.g., whether to proceed with a full review or guideline, direction for future research). Most key informants indicated that evidence analysis/synthesis and quality/strength of evidence assessments were important for decision-making. They reported that rapid reviews in particular were useful for guideline development on narrow topics, policy decisions when a quick turn-around is needed, decision-making for practicing clinicians in nuanced clinical settings, and decisions about coverage by payers/health insurers. Rapid reviews may be more relevant within specific clinical settings or health systems; whereas, broad/national guidelines often need a traditional systematic review.ConclusionsKey informants interviewed in our study indicated that evidence inventories, rapid responses, and rapid reviews have utility in specific decisions and contexts. They indicated that the credibility of the review producer, relevance of key questions, and close working relationship between the end-user and producer are critical for any rapid product. Our findings are limited by the sample size which may have been too small to reach saturation for the themes described.