Marie N. Fongwa

Community-Based Approaches to Strengthen Cultural Competency in Nursing Education and Practice

This article explores existing informal as well as formal approaches that address health disparities in the communities where they occur, enhancing the opportunity to strengthen the cultural competency of providers, students, and faculty. A particular focus centers on the community-based participatory research approaches that involve community members, providing opportunities to develop mutually respectful, trusting relationships through co-teaching and co-learning experiences. With community-based participatory research approaches to community involvement in place, the stage is set for partnerships between communities and schools of nursing to collaboratively design, implement, and integrate informal and formal cultural competence components in nursing curricula.

Language and Regional Differences in Evaluations of Medicare Managed Care by Hispanics

OBJECTIVES This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS((R))) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country. DATA SOURCES CAHPS 3.0 Medicare managed care survey data collected in 2002. STUDY DESIGN The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health. DATA COLLECTION/EXTRACTION METHODS The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish. PRINCIPAL FINDINGS Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care. CONCLUSIONS Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.

Cultural Competencies for Graduate Nursing Education

Nursing is challenged to meet the health needs of ethnic and socioculturally diverse populations. To this end, American Association of Colleges of Nursing (AACN) charged an expert nursing faculty advisory group to formulate competencies for graduate nursing education, expanding them to integrate leadership and scholarship. The Cultural Competency in Baccalaureate Nursing Education served as the springboard for the initiative. In formulating the graduate cultural competencies and the toolkit, the advisory group reviewed all AACN Essentials documents and the cultural competency literature, drew upon their collective experiences with cultural diversity, and used cultural humility as the supporting framework. Six core competencies were formulated and endorsed by the AACN board of directors and key professional nursing organizations. A companion toolkit was compiled to provide resources for the implementation of the competencies. A 1-day conference was held in California to launch the cultural competencies and toolkit. Dissemination to graduate nursing programs is in process, with emphasis on faculty readiness to undertake this graduate educational transformation. The AACN Cultural Competencies for Graduate Nursing Education set national standards to prepare culturally competent nurses at the graduate level who will contribute to the elimination of health disparities through education, clinical practice, research, scholarship, and policy.

The Effectiveness of an Advance Notice Letter on the Recruitment of African Americans and Whites for a Mailed Patient Satisfaction Survey

Objectives:Evaluate an advance notice letter for enhancing patient satisfaction survey response rates in African Americans and Whites. Methods:Randomized trial of an advance notice letter (versus no letter) mailed two weeks prior to a mail satisfaction survey in a random sample of 600 African American and White patients ages 50 and older, stratified by ethnicity, sex, and age. Results:The advance letter was independently associated with a completed survey in Whites (odds ratio = 2.73; 95% confidence interval [CI] 1.66, 4.50), but not in African Americans (odds ratio = 1.24; 95% CI 0.76, 2.02). Being male was independently associated with returning a survey in Whites (odds ratio = 1.86; 95% CI 1.13, 3.06). Younger age (odds ratio = 0.98; 95% CI 0.96, 0.99) was independently associated with a completed survey in African Americans. Discussion:An advance letter prior to a satisfaction survey is associated with increased response rates in Whites, but not in African Americans.

Exploring quality of care for African Americans.

The continuous health disparities for African Americans when compared with Caucasians raise the question of whether health care objectives designed for African Americans actually address their needs and wants. To explore quality-of-care dimensions from the African American perspective, a combined focus group and modified Delphi approach were used. Three quality-of-care dimensions (patient, provider, and setting roles) were deduced from the data. Qualitative thematic narratives were abstracted. Because African Americans emphasized processes of care, their health outcomes may improve if process factors are judged as important as those of input and outcome in an adapted quality-of-care framework.

Reports and Ratings of Care: Black and White Medicare Enrollees

Purpose. This study compared African American/Black and White Medicare enrollees’ perceptions of care. Design and methods. Analyses of the 2002 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) 3.0 survey of 101,189 (White) and 8,791 (Black) Medicare enrollees (82% response rate) randomly sampled from 321 health plans, with data collected via mail (84%) and telephone (16%). Multivariate linear regression models were conducted with the CAHPS® composites and global ratings as dependent variables, controlling for case-mix variables. Results. Blacks reported significantly (p≤.0001, p≤.05) worse experiences with getting care quickly, office staff helpfulness, getting needed care, health plan customer service, rating of specialist care, and rating of the health plan (effect sizes ranging from 0.02 to 0.21). However, they reported better provider communication and rated their personal doctors/nurses and health care more positively (effect sizes ranging from 0.02 to 0.09).

Adherence to treatment factors in hypertensive African American women.

Hypertension (HTN) is a major public health problem in African American women. The disproportionate rate of HTN in African American women makes it a high-priority national health objective. Lack of access to a regular continuous source of care may be particularly significant among African American women because such a source of care is a prerequisite to early diagnosis and successful treatment. Understanding the factors that influence access to care for HTN in African American women will provide the information needed to improve the use of healthcare services and enhance adherence to treatment. Despite the known importance of adherence to successful HTN treatment, few attempts have been made to incorporate the indicators of adherence to HTN treatment into a theoretical model that can be used to guide research and practice with African American women. The adapted Hill-Levine model offers an appropriate framework for studying these phenomena in African American women because factors frequently associated with seeking and using healthcare services are organized in three dimensions, including predisposing, enabling, and reinforcing factors. This article discusses the magnitude of the problem presented by HTN and lack of HTN control in African American women, identifies from the literature the factors related to adherence to treatment in HTN management, in general, and in African American women, specifically, and uses the adapted Hill-Levine model to organize the identified predisposing, enabling, and reinforcing factors associated with adherence to HTN treatment recommendations among African American women.

Comparison of Data Quality for Reports and Ratings of Ambulatory Care by African American and White Medicare Managed Care Enrollees

Objective: Compare missing data and reliability of health care evaluations between African Americans and Whites in Medicare managed care health plans. Method: Consumer Assessment of Healthcare Providers and Systems (CAHPS) 3.0 health plan survey data collected from 109,980 Medicare managed care enrollees (101,189 Whites, 8,791 African Americans) in 321 plans. Participants self-administered the survey and four single-item global ratings of care. Results: Missing data rates were significantly higher for African Americans than Whites on all CAHPS items (p < .0001). Internal consistency reliability estimates for the CAHPS scales did not differ significantly between African Americans and Whites, but plan-level reliability estimates for the scales and global rating items were significantly lower for African Americans than Whites. Discussion: Higher missing data rates and lower plan-level reliability estimates for African American Medicare managed care enrollees suggest caution in making race/ethnicity comparisons. Future efforts are needed to enhance the quality of data collected from older African Americans.

International Health Care Perspectives: The Cameroon Example:

The purpose of this article is to describe the health care system in the West African country of Cameroon and to make recommendations for quality improvement. The Cameroon health care system, used here as an example of the type of system often encountered in developing countries, is described in terms of factors influencing its operation with subsequent health outcomes. International assistance and collaboration with developed countries to improve the Cameroon health care system and health status of the Cameroon people are recommended.

Quality indicator themes among African Americans, Latinos, and Whites.

Elimination of racial/ethnic disparities requires cross-cultural knowledge about quality of care among vulnerable populations. This study used 3 existing data sets to identify quality indicator themes relating to healthcare concerns of African Americans, Latinos, and whites. Using a quality-of-care framework to organize and compare the themes across racial/ethnic groups, we found several unique and 9 common themes. The at-a-glance grid is useful in facilitating culturally competent caring processes in clinical practice.