Crystal Jongen

Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings

BackgroundPersistent disparities in pregnancy and birth outcomes between Aboriginal and Torres Strait Islander and other Australians evidence a need to prioritise responsive practice in Maternal Child Health (MCH). This study reviewed the existing knowledge output on Aboriginal and Torres Strait Islander MCH programs and services with the objective to advance understanding of the current evidence base and inform MCH service development, including the identification of new research priorities.MethodsA systematic search of the electronic databases Informit, Proquest, PubMed, Scopus, Wiley, and Cinahl, and 9 relevant websites was undertaken for the period 1993–2012. The reference lists of MCH program reviews were hand-searched for additional relevant studies which met the eligibility criteria. The study designs of included publications were classified and the characteristics extracted and categorized. Evaluation quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Program (CASP) tool for qualitative studies.ResultsTwenty-three search results were identified for inclusion, with the majority published in 2003–2012. Fifty two percent of publications reported on programs and services operating out of Aboriginal Community Controlled Health Organisations, with antenatal and postnatal care the main intervention type/s, and health promotion/education and advice/support the most common intervention component. Outcomes such as increased antenatal attendance and higher infant birth weights were reported in some intervention studies, however methodological quality varied considerably with quantitative studies typically rated weak.ConclusionThe prevalence of community controlled and/or community-based programs is significant given the health and wellbeing implications of self-determination. While the literature highlights the promise of many intervention models and program components used there are some significant gaps in the documentation and implementation of important MCH interventions. Similarly, while positive health outcomes were reported there are issues with key measures used and study quality. This review highlights the need to improve the quality of evaluations of MCH programs for Aboriginal and Torres Strait Islander women and to address the key evidence gaps in responding to their health and wellbeing needs.

Responding to Indigenous Australian Sexual Assault: A Systematic Review of the Literature

Indigenous Australians experience a high prevalence of sexual assault, yet a regional sexual assault service found few Indigenous Australians accessed their services. This prompted exploration of how its services might be improved. A resultant systematic search of the literature is reported in this article. Seven electronic databases and seven websites were systematically searched for peer reviewed and gray literature documenting responses to the sexual assault of Indigenous Australians. These publications were then classified by response type and study type. Twenty-three publications met the inclusion criteria. They included studies of legal justice, media, and community-based and mainstream service responses for Indigenous survivors and perpetrators. We located program descriptions, measurement, and descriptive research, but no intervention studies. There is currently insufficient evidence to confidently prescribe what works to effectively respond to Indigenous Australian sexual assault. The study revealed an urgent need for researchers, Indigenous communities, and services to work together to develop the evidence base.

Organisational systems’ approaches to improving cultural competence in healthcare: a systematic scoping review of the literature

IntroductionHealthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research.MethodsA literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported.ResultsTwelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level.Discussion and implicationsWe could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities.

The Implementation and Evaluation of Health Promotion Services and Programs to Improve Cultural Competency: A Systematic Scoping Review

Background Cultural competency is a multifaceted intervention approach, which needs to be implemented at various levels of health-care systems to improve quality of care for culturally and ethnically diverse populations. One level of health care where cultural competency is required is in the provision of health promotion services and programs targeted to diverse patient groups who experience health-care and health inequalities. To inform the implementation and evaluation of health promotion programs and services to improve cultural competency, research must assess both intervention strategies and intervention outcomes. Methods This scoping review was completed as part of a larger systematic literature search conducted on evaluations of cultural competence interventions in health care in Canada, the United States, Australia, and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched. Overall, 64 studies on cultural competency interventions were found, with 22 being health promotion programs and services. A process of thematic analysis was utilized to identify key intervention strategies and outcomes reported in the literature. Results The review identified three overarching strategies utilized in health promotion services and programs to improve cultural competency: community-focused strategies, culturally focused strategies, and language-focused strategies. Studies took different approaches to delivering culturally competent health interventions, with the majority incorporating multiple strategies from each overarching category. There were various intermediate health-care and health outcomes reported across the included studies. Most commonly reported were positive reports of patient satisfaction, patient/participant service access, and program/study retention rates. The health outcome results indicate positive potential of health promotion services and programs to improve cultural competency to impact cardiovascular disease and mental health outcomes. However, due to measurement and study quality issues, it is difficult to determine the extent of the impacts. Discussion Examined together, these intervention strategies and outcomes provide a framework that can be used by service providers and researchers in the implementation and evaluation of health promotion services and programs to improve cultural competency. While there is evidence indicating the effectiveness of such health promotion interventions in improving intermediate and health outcomes, further attention is needed to issues of measurement and study quality.

Cultural Competence in Health: a review of the evidence

This resource supports evidence-informed approaches to improving the cultural competence of health service delivery. By reviewing the evidence from Australia, Canada, New Zealand and the US, it provides readers with a clear and systematic overview of the interventions and indicators applied to enable health system agencies and professionals to work effectively in various cross-cultural health care situations. The book highlights the importance of cultural competence and describes the current situation in the studied countries; identifies effective approaches and strategies for improving the situation; reviews the indicators for measuring progress; assesses the health outcomes associated with cultural competence; summarizes the quality of the evidence; and presents an evidence-informed conceptual framework for cultural competence in health. Cultural competence is critical to reducing health disparities and has become a popular concept in these countries for improving access to high-quality, respectful and responsive health care. This book provides policy makers, health practitioners, researchers and students with a much needed summary of what works to improve health systems, services and practice.

Cultural Competency Training and Education in the University-based Professional Training of Health Professionals: Characteristics, Quality and Outcomes of Evaluations

Cultural competence in health care is designed to ensure that health professionals are able to provide quality health care to culturally and ethnically diverse populations. Cultural competence can be effective for improving health professionals’ knowledge, attitudes and skills and patient satisfaction. The impact of cultural competence education and training included in university-based professional training of health professionals is relatively unclear. This study aims to describe the characteristics and assess the methodological quality of published evaluations of cultural competence education and training interventions targeting university based health professionals in training. A systematic search of the cultural competence literature identified 16 published evaluations of cultural competence education and training interventions included in university based professional training of health professionals. Information on the characteristics and methodological quality of included studies was extracted using standardized assessment tools. Nine studies evaluated the integration of cultural competence into health or medical curriculum, four evaluated a cultural immersion experience, and three evaluated cultural awareness education and training. Positive outcomes commonly reported were improvements in students’ knowledge of cultural competence and attitudes towards Indigenous and culturally diverse peoples. The methodological quality of evaluations and the reporting of key methodological criteria were variable. Eleven studies conducted a quantitative and five studies a qualitative evaluation. Strengths of quantitative evaluations included adequate study designs and valid and reliable measurement instruments. Selection bias and poor attrition were the main limitations of quantitative evaluations. Qualitative evaluations were adequate on most methodological criteria but the reporting of ethical and some methodological issues was less than adequate. There is insufficient evidence to provide a strong basis for recommending the inclusion of specific cultural competence education and training strategies in the professional training of university based health professionals. Future evaluations should compare similar types of strategies, and extend their measurement of outcomes beyond those relating to the knowledge, attitudes and skills of health professionals, to those relating to health care outcomes of ethnically diverse peoples.

Health workforce cultural competency interventions: a systematic scoping review

BackgroundAddressing health workforce cultural competence is a common approach to improving health service quality for culturally and ethnically diverse groups. Research evidence in this area is primarily focused on cultural competency training and its effects on practitioners’ knowledge, attitudes, skills and behaviour. While improvements in measures of healthcare practitioner cultural competency and other healthcare outcomes have been reported, there are concerns around evidence strength and quality. This scoping review reports on the intervention strategies, outcomes, and measures of included studies with the purpose of informing the implementation and evaluation of future interventions to improve health workforce cultural competence.MethodsThis systematic scoping review was completed as part of a larger systematic literature search conducted on cultural competence intervention evaluations in health care in Canada, the United States, Australia and New Zealand published from 2006 to 2015. Overall, 64 studies on cultural competency interventions were found, with 16 aimed directly at the health workforce.ResultsThere was significant heterogeneity in workforce intervention strategies, measures and outcomes reported across studies making comparisons of intervention effects difficult. The two main workforce intervention strategies identified were cultural competency training and other professional development interventions including other training and mentoring. Positive outcomes were commonly reported for improved practitioner knowledge (9/16), skills (7/16), and attitudes/beliefs (5/16). Although health care (6/16) and health (2/16) outcomes were reported in some studies there was very limited evidence of positive intervention impacts. Only four studies utilised existing validated measurement tools to assess intervention outcomes.ConclusionTraining and development of the health workforce remain a principle strategy towards the goal of improved cultural competence in health services and systems. Diverse approaches are available to increase health workforce cultural competence. However, the effects of interventions beyond practitioner knowledge and attitudes remains unclear. Assessment of practitioner behavioural outcomes as well as measures of intervention impact on healthcare and health outcomes are needed to build a stronger evidence base.

Services and Programs to Improve Cultural Competency

Programs and services that are tailored or adapted to meet the specific needs of particular cultural or ethnic groups are a crucial component of integrated culturally competent healthcare systems. There are many different approaches which can be taken to ensure that healthcare programs and services are more appropriate for populations who do not have their healthcare needs adequately met by mainstream services. In this chapter, we explore the various strategies which have been used in the reviewed literature to increase the cultural appropriateness of healthcare programs and services. Examples of different community-, culture- and language-oriented strategies are provided. The outcomes across evaluations, including those related to healthcare and health outcomes, are discussed along with study quality and measurement issues.

Health Workforce Development Interventions to Improve Cultural Competence

Improving the cultural competence of the health workforce is the original and still the most common cultural competence intervention strategy. The primary focus in research is on the effects of cultural competency training on health practitioners’ knowledge, attitudes, skills and behaviour. Studies demonstrated improvements in measures of practitioner cultural competence. However, there are ongoing concerns about the strength and quality of the evidence base, and whether increased practitioner cultural competence improves healthcare and health outcomes. This chapter explores the intervention strategies, outcomes and measures utilised in cultural competence interventions targeting the health workforce.

Health Organisation and System Cultural Competence Interventions

Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competence strategies aimed at health promotion initiatives, workforce development and student education. This chapter aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically searching, selecting and synthesising existing publications to map key concepts, types of evidence and gaps in research.