Carolyn J Feuerstein

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.

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.