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Effective Health Care Program

Improving Cultural Competence to Reduce Health Disparities

Systematic Review

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Structured Abstract

Objective

To examine existing system-, clinic-, provider-, and individual-level interventions to improve culturally appropriate health care for people with disabilities; lesbian, gay, bisexual, and transgender (LGBT) populations; and racial/ethnic minority populations.

Data sources

Ovid MEDLINE®, PsycINFO®, Ovid Embase®, and the Cochrane EPOC (Effective Practice and Organisation of Care) register; hand searches of references of relevant studies.

Review methods

Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and other observational studies with comparators that evaluated cultural competence interventions aimed at reducing health disparities in the formal health care system. Two investigators abstracted data and assessed risk of bias. Given the sparse and patchy literature, which precluded pooling, a qualitative analysis is provided.

Results

Over 37,000 nonduplicated English-language citations were reviewed; 56 unique studies were identified as of June 2015: 20 randomized controlled trials (RCTs) and 5 observational studies for individuals with disabilities; 5 RCTs (6 manuscripts) and 6 observational studies for LGBT populations; and 14 RCTs (15 manuscripts), 4 observational studies, and 2 systematic reviews for members of racial and ethnic minorities. Interventions fell into four broad categories: (1) provider trainings and education; (2) interventions providing alteration of an established protocol, or the delivery of an established protocol, to meet the needs of a target population; (3) interventions prompting patients to interact with the formal health care system or health care providers; and (4) interventions aimed at providing culturally competent care at the point of service.

Educational programs and trainings to improve professional students' and providers' cultural competence behavior are the most prevalent type of cultural competence intervention. Two existing high-quality systematic reviews of provider educational interventions for racial/ethnic minority populations found low-strength evidence that cultural competence training had mixed effects for intermediate outcomes and no effect on treatment outcomes. Sixteen studies aimed at changing provider attitudes and beliefs through training or curriculums were identified for the disability population. Eleven of these studies focused on reducing professional stigma toward people with serious or chronic mental illness; five focused on changing professional attitudes and beliefs about people with physical or intellectual disability. Three educational interventions were identified for the LGBT population. Several short-term effects were evaluated; however, long-term effects of provider training on provider cultural competence behavior in the clinical setting and subsequent patient health outcomes have not been evaluated for the disability and LGBT populations. Two included studies reported a potential harm from provider training: an increase in negative attitudes or stigma resulting from intervention.

Interventions providing alterations of an established protocol were concentrated in the racial/ethnic minority populations. The 12 studies of culturally tailored health care interventions for racial/ethnic minority populations focused primarily on treatment of chronic physical or mental health conditions (e.g., diabetes, depression, substance abuse). Two psychological interventions were also tailored for members of the LGBT population.

Another common type of intervention was to provide additional resources to encourage or empower patients to interact with the formal health care system and/or health care providers. The stated aims of these types of interventions were to increase receipt of screenings for which disparities are well documented (e.g., Pap tests for people with mobility impairments or colorectal cancer screening among Latino immigrants) or to help patients engage in medical decisionmaking. These studies met inclusion criteria if the intervention was conducted by a medical professional in a formal health care system. One potential limitation of these types of interventions is that they rely on strong identification with a common culture. The population groups highlighted in this review are large and diverse. Creating an intervention for "African Americans" or "women who have sex with women" may be differentially effective for specific subpopulations.

The most common culturally competent point-of-service interventions were documents, similar to a hand-held medical record, that patients carried to their appointments to prompt providers to evaluate areas of known disparity for a specific population. These interventions may be coupled with provider notices or trainings. Virtual interventions were also considered culturally competent point-of-service interventions for some people with disabilities, as they create access in a unique way. These interventions are seen as conceptually parallel to infrastructure changes that improve access for people with physical disabilities.

For the majority of included studies, the risk of bias was high. The most common methodological problems were lack of randomization to treatment, lack of attention control, little or no followup, and failure to report unintended consequences. Large segments of vulnerable or disadvantaged populations--such as children with disabilities; people who are gender nonconforming or transgender; or numerous racial or ethnic groups, including Native Americans or Alaskan Natives--remain essentially invisible in the cultural competence literature. The issue is compounded for people who are members of more than one priority population.

Conclusions

None of the included studies measured the effect of cultural competence interventions on health care disparities. Most of the training interventions measured changes in professional attitudes toward the population of interest but did not measure the downstream effect of changing provider beliefs on the care delivered to patients. Interventions that altered existing protocols, empowered patients to interact with the formal health care system, or prompted provider behavior at the point of care were more likely to measure patient-centered outcomes. The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way. The term "cultural competence" is not well defined for the LGBT and disability populations, and is often conflated with patient-centered or individualized care. There are many gaps in the literature; many large subpopulations are not represented.