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Butler M, McCreedy E, Schwer N, et al. Improving Cultural Competence to Reduce Health Disparities [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Mar. (Comparative Effectiveness Reviews, No. 170.)
Introduction
In the late 1970s and 1980s, the concept of cross-cultural medicine emerged from recognition and advocacy surrounding cultural and linguistic barriers to health care.75 In the early 1990s, increased emphasis on health care disparities expanded the focus of cultural competency programs and trainings beyond immigrant populations and interpersonal aspects of cross-cultural health care. New focal areas included health care systems and all racial and ethnic minority populations experiencing health care disparities. With the aim of improving access and reducing health care disparities,153 cultural appropriateness was framed as addressing cultural barriers to care and dimensions of provider quality.154 Views of cultural competence (CC) have continued to evolve along with understanding of the structural sources of health disparities. New terms such as “structural competence” have been proposed for provider training to emphasize structural aspects of health inequalities.155 On the other hand, interventions to improve cultural competence of the health care system may reflect nuanced conceptualization of the multilevel sources of disparities, transcending the origins of the term “cultural competence” in cross-cultural medical encounters.
Past systematic reviews have found an association between self-reported racism and illness among people of minority groups.156,157 Perceptions of discrimination based on race/ethnicity are also associated with worse patient-reported experiences of care.158 Past reviews have also found evidence of racism by health care providers toward minorities, although little is known about the extent of provider racism or how to measure it.159,160 Personally mediated racism includes underlying (often unacknowledged) prejudices among clinicians that cause them to treat others differently, with clinical consequences, according to race/ethnicity.161 Individual level racism can also manifest as omissions such as lack of services or failure to convey a welcoming environment.
In many instances, discrimination against minorities is exacerbated by and rooted in socioeconomic issues. Minorities are more likely to lack health insurance coverage and they are disproportionately covered by public programs like Medicaid, where reports of insurance-based discrimination (being treated unfairly by health care providers based on enrollment in public insurance or a lack of insurance) are higher.162-164 Those who report insurance-based discrimination also report restricted and delayed access to care.165
Health Disparities
The Institute of Medicine defines health care disparities among population groups as the difference in treatment or access not justified by the differences in health status or preferences of the groups.162 Disparities in health outcomes for minority groups defined by race and/or ethnicity are an enduring challenge within the health care system.166 For example, compared with whites, both African Americans and Latino Americans encounter higher rates of preventable hospitalizations and complications from chronic diseases.166 Difficulties in documenting health care disparities include the presence of multiple racial/ethnic subpopulations and ways of defining these subpopulations.162
Cultural Competence
Cultural competence has been variously defined and does not have a consensus definition. A foundational definition for racial and ethnic cultural competence was developed in 1989 through the Georgetown University Child Development Center: “Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. ‘Competence’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.”167
An updated model of cultural competence produced by the National Center for Cultural Competence at the Georgetown University Center for Child and Human Development more explicitly posits cultural competence as an organizational or system capacity which requires understanding of the social, cultural, political, and economic contexts of health care organizations.168 In this model, improved cultural competence leads to reduction in health care disparities as well as decreased bias and discrimination.
Scope and Key Questions
Scope of the Review
This review examines the evidence for cultural competence interventions at the system and provider level designed to address known or suspected health disparities in people from race/ethnic groups. We do not address policy-level evaluations.
Clarity about which interventions are within the scope of cultural competence versus those outside is important, but challenging. This review's main focus is on whether cultural competency interventions change health care providers' behaviors (such as communication and clinical decisionmaking), the patient-provider relationship, and/or clinical systems to ultimately result in better outcomes. The review focuses on interventions within the formal health system (such as located at clinic, led by a nurse, or treatment of a specific health condition that could be delivered within the formal health care system) rather than on public health outreach programs and other parallel systems outside the formal system. Within the clinical context, interventions aimed at improving care for all patients (such as patient-centered care or collaborative care) were excluded unless the intervention specifically addressed a cultural competence component and was compared with care without that component. Similarly, treatment interventions for health conditions were not in scope unless the intervention was specifically adapted to people from a particular racial/ethnic group and tested against a nonadapted and otherwise comparable intervention. The primary outcomes of interest were reductions in disparities among populations for a given health outcome measure. Since no studies directly evaluated disparity reduction, we focused on health outcomes and other patient-centered outcomes such as patient perceptions of cultural competence.
Key Questions
KQ: What is the effectiveness of interventions to improve culturally appropriate health care for racial/ethnic minority children and adults?
PICOTS
Table 14 provides the populations, interventions, comparators, outcomes, timing, and settings (PICOTS) of interest. The analytic frameworks can be found in Chapter 1 and Appendix A.
Table 14
Review PICOTS—racial/ethnic populations.
Methods
This review followed the methods suggested in the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews (available at www.effectivehealthcare.ahrq.gov/methodsguide.cfm); certain methods map to the PRISMA checklist.12 We recruited a technical expert panel to provide high-level content and methodological expertise feedback on the review protocol. The protocol was posted on July 8, 2014, at www.effectivehealthcare.ahrq.gov. This section summarizes the methods used.
Literature Search Strategy
We searched Ovid MEDLINE®, PsychInfo, and Cochrane EPOC from 1990 to June 2015. Keywords and MeSH terms to capture racial, ethnic, and immigrant population, cultural competence, and disparities were used. Searches and screening were performed iteratively to identify concept boundaries and tighten the working definitions and eligibility criteria. The final search algorithms are provided in Appendix B. We also manually searched reference lists from systematic reviews and employed back and forward searching of key articles recommended by experts.
Study Selection
We reviewed bibliographic database search results for RCTs, systematic reviews, nonrandomized controlled trials, before and after case reports with comparators, and interrupted time series studies published in English language relevant to our PICOTS framework. All studies identified at title and abstract as relevant by either of two independent investigators underwent full-text screening. Two investigators independently performed full-text screening to determine if inclusion criteria were met. Initial search results were vetted by the full team, and decision rules, discussed below, to identify studies that met inclusion criteria were established for second and subsequent rounds of screening. The decision rules were designed to capture the distinction between how to make the health care system more culturally competent, not whether there is culturally competent care. Differences of opinion regarding eligibility were resolved through consensus adjudication. Articles excluded at full text are provided in Appendix C with reasons for exclusion.
Eligible studies tested an intervention to provide culturally appropriate health care to children and adults from race/ethnic minority groups. We excluded interventions in which cultural tailoring was limited to language translation, patient-provider concordance, or culturally-tailored media (e.g., brochures, videos). The intervention had to be designed to improve cultural competence of the health care system. Only translating or adding a multicultural feature to patient materials was not sufficient. Patient-provider matching alone (based on race/ethnicity) was also not sufficient for inclusion. We excluded studies that examined racial or ethnic patient-provider matching as a sub-analysis of a larger study.169,170
We also excluded studies that lacked an appropriate comparator to test the cultural competence component(s) of the intervention. Because cultural competence was initially conceived for race/ethnic populations, we were stricter in our requirement of an appropriate comparator. Thus we excluded studies designed to compare variation in intensity rather than exposure to the cultural competence component(s) (e.g., authors described the comparator as low-dose, low-intensity, or minimal); studies of interventions that were educational or elective in nature that compared a number of classes or visits in the intervention group versus waitlist, media (such as a brochure), one class only, or the control was otherwise not comparable; multisession, multicomponent educational interventions for chronic disease (such as diabetes lifestyle education with some degree of cultural tailoring) versus usual care; and studies otherwise designed without manipulation of cultural competence variables (such as comparing the delivery format of two culturally tailored interventions). A common design is to compare individual or group visits or calls over weeks, months, or years versus usual care (no outreach). This design may be appropriate to test the effectiveness of increased treatment intensity on disease management outcomes, but this type of study does not contribute to the evidence base regarding the effectiveness of cultural competence. At the strongest level, we identified a smaller set of included studies that examined interventions to improve cultural competence with an experimental design.
Eligible settings were U.S. inpatient, outpatient, and community settings in which patients are interacting with health care providers.
We first assessed the relevance of systematic reviews that met inclusion criteria. If we determined that certain Key Questions or comparisons addressed in the previous systematic review were relevant to our review, we assessed the quality of the methodology using modified AMSTAR criteria.171
Data Extraction, Synthesis, and Presentation
We evaluated the risk of bias in included studies according to study design using criteria from the Cochrane risk-of-bias tool in interventional studies (Appendix D). Given the paucity of literature identified, the heterogeneity of the study populations and interventions, small study samples, the lack of details for complex interventions and comparators, and the high risk of bias assessment for most of the included studies, we determined the strength of evidence for cultural competence interventions, in general, to be insufficient and thus we were unable to draw meaningful conclusions from the literature. Therefore, we focused on summarizing the results into evidence tables and conducted a qualitative synthesis, grouping synthesis results using emergent patterns from identified interventions, and evaluating the challenges of the literature that present barriers to forming inferences from study results. Where we were able to use previously published systematic reviews that evaluated strength of evidence, we report that review's strength of evidence finding. One investigator abstracted the relevant data from eligible trials directly into evidence tables. A second investigator reviewed evidence tables and verified them for accuracy.
Results
Literature Search Results
We identified 12,533 unique English language citations (Figure 6) from 1990 to June 2015. After excluding articles at title and abstract, full texts of 223 articles were reviewed to determine final inclusion. Twenty-one articles representing 18 unique studies met eligibility criteria. Additionally, one systematic review and one overview of systematic reviews addressed provider education.51,172 We report the strength of evidence assessed by the previously published systematic review of provider training. Six studies examined interventions to improve cultural competence in patient-provider interactions: two randomized trials at the physician level,173,174 one cluster-randomized trial,175 one randomized trial at the patient level,176 and two controlled trials.177,178 Ten randomized trials and two controlled observational studies examined interventions to improve cultural competence/cultural appropriateness of clinical treatment.179-187 Individual studies were generally high risk of bias (Appendix D). Since the risk of bias and heterogeneity of the studies precluded any strength of evidence other than insufficient, we describe the studies by emergent patterns.
Figure 6
Literature flow diagram—racial/ethnic populations.
The two reviews and 18 individual studies fell into three categories: interventions of provider training to improve cultural competence (n=1 overview of systematic reviews, n=1 systematic review); interventions to improve provider/patient contact (n=6); and culturally tailored interventions (n=12).
Patient populations represented in the 18 individual studies included African American, Hispanic/Latino American, Asian American (East Asian or Korean ethnicity), and American Indian and Alaska Native (AI/AN). Among the six studies that examined interventions to improve cultural competence in patient/provider interaction, three studies sampled African American patient populations and three focused on Hispanic/Latino Americans. Of the 12 studies that examined culturally tailored interventions for treatment of specific health conditions, three studies included African Americans, three included Asian Americans, one included AI/ANs, and six included Hispanic/Latino Americans, one of which included both African American and Latino men (Table 15).188 No studies addressed culturally competent care specifically for children or older adults.
Table 15
Cultural competence intervention type by race/ethnicity and health condition.
Interventions for Provider Education
We identified two high quality systematic reviews that addressed provider education interventions. (See Appendix D for review quality assessment.) A recent Cochrane systematic review by Horvat et al.51 included five RCTs that evaluated the effect of provider training on patient outcomes for culturally and linguistically diverse (CALD) populations and found low-strength evidence that cultural competence training had mixed effects for intermediate outcomes and no effect on treatment outcomes. Table 16 presents the reported findings in detail.
Table 16
RCTs of cultural competence provider training for CALD patients compared with no training in primary care setting in high-income countries.
The second review was a recent overview of systematic reviews by Truong et al. that included 19 individual reviews.172 We synthesized the provider training results of studies included by Truong et al. in relation to Horvat et al. (see Appendix Table D3). (Since many of the studies in the reviews included by Truong et al. were not limited to provider training, we also screened these studies for possible inclusion based the criteria of this review.) We cross-walked the included sets of studies and treated additional studies identified in the Truong et al. overview as a sensitivity analysis of the Horvat et al. results.51
Of the 19 systematic reviews included by Truong et al., six focused on patients only and 13 had provider training within the review scope, with 5/13 reporting additional observational data on provider training outcomes broadly within the scope of Horvat et al. and our review.192-196 Other topics explored by the reviewed literature include provider training specific to Australia197 and international experiences in nursing education.198,199 One review that aimed to study structures and processes in the development of a culturally competent workforce included primarily descriptive articles,200 and a contextual review included articles that normally would not be included in a systematic review of interventions. Two reviews included studies of provider training that fully overlapped with those included by Horvat et al.201,202 and one review included one provider training study that did not add data to the outcomes reviewed by Horvat et al.203
Truong et al. included an earlier influential review by Beach et al.192 describing the weak study designs overall and lack of uniformity in specifying interventions and measuring outcomes. Much of the literature on health care provider training relies on self-reported provider outcomes.193,199,204 Beach et al. reported positive evidence for the effect of cultural competence training on provider knowledge and attitudes, some evidence that training improves patient satisfaction, and no studies that tested patient treatment outcomes.
The additional evidence contributed by observational studies of provider training within the Truong et al. overview of reviews aligned with the results found by Beach et al.
Observational studies, often with a pre/post design, consistently reported improvement in provider knowledge and attitudes, and patient evaluations of care. However, RCTs have found low strength evidence of no effect on provider knowledge or treatment outcomes, mixed evidence for patient evaluations of care, and low strength evidence of effect on health behaviors and mutual understanding based on single studies.51
The eight observational studies from across the five systematic reviews included by Truong that were not included by Horvat or Beach did not add data to three of the five outcomes assessed by Horvat et al.: patient treatment outcomes, health behaviors, and involvement in care. Study designs were primarily pre/post, which precludes strong conclusions. Six observational studies reported improvement in provider knowledge/attitudes after cultural competence training, similar to the findings of Beach et al.193-196 In contrast, one RCT reviewed by Horvat et al. found no evidence for the effectiveness of provider training on provider knowledge.205 This study examined clinician awareness of racial differences in the quality of diabetes. Two observational studies reported improved evaluations of care: patient family satisfaction, perceived environmental changes favoring patients' interests and ‘ethnic affinity’ toward staff.196 However for this outcomes domain, Horvat et al. reported mixed results. Two RCTs conducted outside of the United States indicated no effect,206,207 while one RCT showed improvements in patient perceptions of their health care providers after cultural competence training.208
Interventions To Improve Patient/Provider Interactions
Diverse interventions were used in the six studies that addressed cultural competence in patient/provider interactions (Table 17). Two studies broadly addressed cultural competence in medical visits by African American patients through the use of a “common identity” treatment (to enhance their sense of commonality) with racially discordant patients and physicians174 or administration of a pamphlet prior to a medical visit.178 Although we generally excluded culturally tailored pamphlets, we included the Ask Me 3 pamphlet intervention because it was designed specifically to promote patient-provider interaction rather than to communicate specific health information.178 Two studies examined educational interventions to promote decisionmaking skills and patient empowerment among Latino mental health patients.176,177 One study examined a culturally tailored collaborative care intervention for physicians aimed at improving the care of African American mental health care patients.175 Lastly, one study examined a culturally sensitive, multi-level intervention (an educational video and brochure for patients along with a patient-delivered paper-based reminder for the physician) designed to improve colorectal cancer screening rates among Latino immigrant primary care patients.173
Table 17
Interventions to improve patient/provider interactions for racial/ethnic minorities.
Whereas most studies tended to compare the intervention with usual care, one study compared patient-centered, culturally tailored collaborative care (clinician training to enhance participatory decisionmaking and care management focused on explanatory models, socio-cultural barriers, and patient preferences) versus a carefully-reported intervention defined as standard collaborative care.175
Only one of the six studies assessed clinical outcomes (Table 18).175 This cluster-randomized trial of patient-centered, culturally tailored collaborative care versus standard collaborative care reported a full spectrum of outcomes ranging from depressive symptom reduction and treatment rates to patient ratings of clinicians' participatory decisionmaking and ratings of care managers' helpfulness in identifying concerns, identifying barriers, providing support, and improving treatment adherence. Five of the six studies included patient perceptions as outcomes. Five included outcomes related to health care utilization or adherence, and one of these reported only adherence.173 Two studies evaluated patient-reported activation and empowerment177 or self-management.176 One study of a common identity treatment for racially discordant patients and physicians evaluated both patient and provider perceptions of being on the same team, patient trust of their physician and physicians in general, patient perception of patient-centeredness, and patients' adherence to physician recommendations.174 One study reported the Perceived Cultural Competency Measure, as well as patient satisfaction and perception of participation and fair procedures.178 No studies examined adverse effects or unintended negative consequences of the interventions.
Table 18
Outcomes for interventions to improve provider/patient interactions among racial and ethnic minority populations.
All six studies of cultural competence in patient/provider interaction reported that their study outcomes support the effectiveness of the intervention.173-178,184 One study of an educational intervention for patients reported effectiveness in self-reported patient activation and self-management but no effect on treatment retention.176 One study reported no overall differences among groups, but in a post hoc subanalysis, people who were seeing their usual provider were more satisfied if they used the pamphlet.178
Culturally Tailored Interventions
The 12 studies of culturally tailored health care interventions focused primarily on treatment of chronic physical or mental health conditions (e.g., diabetes, depression, substance abuse) (Table 19). Studies including African American patients examined interventions for diabetes,182 depression,184 and substance abuse;188 those including Hispanic/Latino Americans examined interventions for cancer screening,179 diabetes and depression,189 pregnancy,186 and substance abuse;180,185,188 those including Asian Americans examined interventions for diabetes,190 phobia187 and smoking cessation,183 and the study including AI/ANs examined an intervention for smoking cessation.191
Table 19
Culturally tailored interventions among racial and ethnic minority populations.
Eight of the 12 studies of culturally tailored health care interventions directly compared a culturally tailored version with a standard version of the same intervention.179,180,184,185,187,188,190,191 Three of these studies involved a single session of psychological treatment185,187 or a single phone call from a nurse.179 One study compared four sessions of culturally tailored versus standard individual counseling for smoking cessation, with both groups also receiving 12 weeks of varenicline.191 The counseling sessions were designed to be the same except for the addition of culturally tailored components to address tobacco-related issues among Menominee and other AI/AN smokers. Another study compared 12 weeks of culturally accommodated versus standard cognitive-behavioral substance abuse treatment (S-CBT).180 Cultural accommodation involved modifying cultural variables for relevance to Latino adolescents, resulting in a culturally tailored treatment manual. Similarly, one observational study compared 16 weeks of culturally accommodated versus standard cognitive behavioral therapy (manualized) for depression among African American women with multiple psychosocial stressors.184 One study examined a culturally adapted version of Real Men Are Safe (REMAS-CA), an HIV prevention intervention for Hispanic or African American men in substance abuse treatment.188 Results of the pilot test of REMAS-CA were compared with results of the original REMAS trial among minority participants. One observational study compared a culturally specific program for Asian Americans with type 2 diabetes with white patients with diabetes.190 Both groups received care within the same diabetes center and time period.
The other four studies involved less direct comparisons. In a study of diabetes education for black women, the experimental group received slightly more sessions (11 weeks versus 10 weeks) and the intervention had a stronger cognitive behavioral focus than the control group, in addition to being cultural tailored versus nontailored.182 In one study of a culturally tailored intervention for smoking cessation among Korean Americans, the experimental group received a 40-minute intervention while the nontailored group received a 10-minute intervention, but the duration was 8 weeks for both groups.183 One study that included predominantly Hispanic diabetes patients with major depression symptoms compared socio-culturally tailored collaborative care with enhanced usual care.189 Lastly, one study that included pregnant, immigrant Latinas compared Prenatal Partners (cultural brokers who showed participants how to navigate the health system, self-advocate, and communicate with providers) with usual care.186
Most studies of culturally tailored interventions reported clinical outcomes and the majority also reported health care utilization or adherence (Table 20). One study reported therapeutic working alliance as perceived by the patient and therapist,187 one study reported perceived provider support for diet and exercise,182 and one reported patient satisfaction.180 One study examined adverse effects and reported no serious adverse effects.191
Table 20
Outcomes for culturally tailored interventions among racial and ethnic minority populations.
Three studies reported no results in support of cultural tailoring,179,190,191 with one of these studies reporting improvement in both groups and different factors contributing to lack of success among people receiving care at the culturally specific clinic.190 One study reported no overall results favoring tailoring but supportive results mediated by cultural variables.180 The other eight studies reported positive findings for culturally tailored interventions. For two studies, both culturally tailored and nontailored interventions were effective with some evidence of additional benefit for the culturally tailored intervention.182,187 There was some selective emphasis in outcome reporting,183 and one study did not test outcomes for statistical significance.
Discussion
Overview
Overall, the cultural competence intervention literature for racial/ethnic groups is still sparse and patchy. While several studies assessed changes in clinical outcomes, studies that directly address whether culturally competent interventions reduce the disparities gaps among race/ethnic groups and whites are not present in the literature. A few larger minority populations were represented in the literature, but many were absent, such as South Asian, or minimally represented, such as AAI/AN. None of the included studies specifically addressed people of multiracial or mixed ethnic background. While reviews were available on provider education interventions, only one individual study was targeted at the level of the health system.173
To move beyond provider education, we evaluate both studies clearly labeled as cultural competence and studies of diverse interventions aimed to improve the care and/or reduce health care disparities for minority patients at the provider and system level which were grounded in a variety of conceptual or theoretical models perhaps contributing to cultural competence. Of those studies that rose to the level of experimentally testing cultural competence interventions, we found a heterogeneous mix of studies that loosely fit into two intervention categories: (1) interventions to improve patient/provider interactions and (2) culturally tailored interventions targeted to specific racial or ethnic groups.
The interventions to improve patient/provider interactions are heterogeneous across target populations and interventions designs, and very few studies in the set included outcomes to assess changes in patient-centered outcomes. Cultural competence interventions targeting patient/provider relationships are important. Interventions based on theories or frameworks focused on improving communication skills or shared decisionmaking may change the patient/provider relationships. The limited results in this area coincide with the status of disparities research generally. A prior systematic review of disparities interventions (1979 – 2011) found that most interventions target patients (50 percent) and community members (32 percent), whereas 7 percent target providers, 9 percent target the care team, 3 percent target the organization, and 0.1 percent target policy.209
Cultural tailoring of health care interventions was the largest set of newly identified studies. This heterogeneous set had several challenges. It often lacked transparency regarding what constitutes the cultural accommodation, providing little to no detail regarding the specific features that constitute cultural tailoring of the intervention. A minority of articles publish detailed reports of the process of culturally tailoring interventions.175,191,209,210210,211 Cultural tailoring was often a small component of a multicomponent intervention focused on patient education and self-management. This type of intervention may be suitable for clinical, practical, and ethical reasons, but it does not lend itself to isolating and testing the effectiveness of cultural competence as a specific component of the intervention. Further, few studies of culturally tailored health care interventions measured patient perceptions, and none assessed factors (such as attitudes and perceptions) that are shared among underserved minorities, such as medical mistrust, experiences of discrimination, immigrant status, or problems communicating with their providers. The inclusion of these factors would help our understanding of how and why interventions might transfer to other groups.
Understanding the extent to which certain interventions could successfully transfer across groups would help leverage the current research. Whether an intervention delivered to and/or tailored based on a sample population can be generalized to others within the same race or ethnic group, such as Hispanic Americans living in different geographic regions or with different levels of acculturation, or across mixed backgrounds remains unknown. This is of particular concern considering the predominance of single studies of interventions that were culturally adapted to a specific racial/ethnic population. Definitions of racial or ethnic minorities cannot necessarily be cleanly applied within clear boundaries. On the other hand, studies of interventions designed to improve patient/provider interactions were relatively more universal in their approaches to cultural competence through coaching patients, facilitating patient-physician shared decisionmaking, or the use of reminders in the context of a multi-level intervention.
Our review excluded many types of intervention studies described as culturally competent but lacking a study design that would test cultural competence. Many studies did not use a comparison group that received a nonculturally tailored version of the intervention received by the experimental group. This design issue is exemplified by research on patient education for people in racial or ethnic minority groups with type 2 diabetes. In a recent Cochrane systematic review of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus,2112 only one of 33 studies182 compared a culturally tailored intervention group with a nontailored active control group. One additional study included by Attridge et al. used an active control group but did not test cultural competence; culturally tailored symptom management was compared with culturally tailored diet and weight management.212 Half of the included studies compared diabetes education with usual care (waitlist or no outreach), and in other cases the control group received a token intervention such as brochures, newsletters, or occasional phone calls.
Patient navigation is an area of active research that overlaps with cultural competence. Interventions in this realm are often described as culturally competent but are generally not studied with a design that could test the effectiveness of cultural competence. We found no studies that directly compared culturally tailored versus nontailored patient navigation. Cultural tailoring may be one aspect of patient navigation, but such interventions aim to address barriers to care broadly. Similarly, collaborative care is occasionally described as culturally competent. However, this language may reflect different contextual settings for collaborative care interventions rather than evaluation of the effectiveness of cultural competence. For example, one excluded study compared a safety net clinic serving a minority population with collaborative care versus general clinics (without collaborative care, a safety net function, or a focus on minority populations).213 This design does not provide evidence regarding the effectiveness of cultural competence.
Community health workers are another area of active research where the language of cultural competence is often used, but where interventions are generally not studied with a design to evaluate the effectiveness of cultural competence. Interventions using community health workers range from advocacy and patient education to disease management (see http://mnchwalliance.org/explore-the-field/evidence-2/). Some studies framed as addressing disparities through community health workers hired a person from the target racial or ethnic group to deliver the intervention, but were designed to test the effects of two levels of treatment intensity214 or 2 years of asthma coaching versus usual care.215 Thus, such studies were not designed to test the effects of a culturally tailored versus nontailored intervention, as were the studies of interventions included in this review.
Although prior systematic reviews concluded that evidence supports the use of community health workers who are culturally competent,195,203 the interventions included in these reviews were heterogeneous. Fisher et al. concluded that community health workers “are among the most successful strategies that emerged from our literature review” despite noting that conditions and interventions were heterogeneous, no studies were designed to examine the effectiveness of the intervention in reducing health disparities, and “none of the studies actually addressed the extent to which the cultural aspects of these interventions brought about the improvements in care, apart from the general mechanisms of quality improvement or public health strategies inherent in the interventions” (p 276S-277S).203 The studies included by Henderson et al. had similar weaknesses.195 We found no studies that compared culturally tailored versus nontailored interventions delivered by community health workers.
Racial/ethnic characteristics often overlap with sociodemographic characteristics that increase the likelihood of disparities, such as socioeconomic status and immigration status. Often, interventions aim to address multiple types of barriers to health care and health outcomes, rather than isolating cultural competence factors. This may be appropriate depending on study goals, but in this case the effectiveness of cultural competence factors is assumed rather than tested. Additionally, the language of “cultural tailoring” may be used in multiple contexts that may be distinct from cultural adaptations based on race and ethnicity. For example, one excluded study described the cultural tailoring of the intervention as “culturally relevant to socioeconomically disadvantaged women,”216 exemplifying the issue that approaches used to address health disparities for racial or ethnic minorities may also serve populations of low socioeconomic status. Of the studies included in this review, over half of the sample populations were described as low income and/or low education.
Lack of uniformity in cultural competence definitions and frameworks has already been noted.172 This lack of consensus in defining and evaluating cultural competence may contribute to the heterogeneity of interventions and lack of reported detail on cultural competence components, especially for cultural tailoring interventions, although word count limitations may also constrain reporting cultural adaptation in detail. One of the most thoroughly described interventions was reported in an article with a much higher word count than typical for this literature.191
Research Directions
As noted above, interventions often aim to address multiple types of barriers to health care and health outcomes for racial and ethnic minorities. While this is understandable, given the correlation of racial and ethnic minorities and low socioeconomic status, research designed to isolate the effectiveness of cultural competence factors is needed if and when the specific goal of the research is to examine the effectiveness of interventions to improve cultural competence, as opposed to increasing the reach of care for vulnerable populations. However, we emphasize that both effectiveness and reach are essential for increasing the impact of cultural competence interventions. Such effectiveness research should specifically test components seen as directly related to cultural competence. For example, patient/provider concordance may jumpstart trust and facilitate communication, but other social factors may interfere with the assumed benefits. Likewise, culturally matching community health workers may help address language barriers and facilitate more open communication than one would see with a concordant physician because of the more similar shared status between the patient and the community health worker. Our understanding could be advanced by testing the role played by the community health worker and feeding back to the health system what is learned from the patient rather than merely conveying the health promotion or disease management information the health system deems important.
Research that aims to clarify which cultural competence components are relatively universal and easily generalizable and which are truly group or sub-group specific would also make a contribution. One obvious place to extend the research would be in examining what works for people of multiracial or mixed ethnic backgrounds.
Most of the included studies measured only clinical outcomes (such as change in symptoms) or intermediate outcomes (such as health care utilization or adherence). These studies did not provide direct evidence that improved cultural competence leads eventually to reduced disparities. Studies that examine only clinical outcomes and/or utilization/adherence may point the way towards interventions that may reduce disparities via improved cultural competence, but the last step is still inference rather than direct demonstration. A more explicit link between cultural competence interventions and clinical outcomes could be made by combining clinical outcomes with intermediate measures of improved cultural competence, such as patient perceptions of cultural competence. Directly connecting observed changes in outcomes and improved cultural competence is important considering the challenges in clearly isolating cultural competence as a concept.
The included studies primarily focused on comparing interventions within race/ethnic groups, not among groups, thus inferences about reducing disparity gaps would need to be based on indirect comparisons. One cohort study directly compared Asian American and white people with type 2 diabetes. Although this study did not find differences between groups at baseline and therefore did not directly examine disparities, this study exemplified the type of design that could provide direct evidence regarding culturally adapted interventions that aim to reduce disparities.190
Further, nearly all of the included studies evaluated outcomes of a single group, rather than examining whether the intervention reduced health disparities via improved cultural competence. Comparing clinical outcomes by race/ethnicity could indicate a reduction in disparities in those outcomes (such as if/whether the intervention benefitted a nondominant group more than the dominant group). Studies that assess improvement in cultural competence and show differential results in clinical outcomes among racial/ethnic groups would provide more direct evidence that cultural competence is a pathway to reduced disparities in health outcomes.
Limitations
The major limitation of this review is the difficulty drawing boundaries between patient-centered care and cultural competence, particularly regarding interventions designed to improve patient/provider interactions. Individually tailored interventions, such as individualized cancer risk assessment in cancer screening education,217,218 were excluded to distinguish cultural competence interventions from a related concept, patient-centered care.75 Individually versus culturally adapted interventions may prove to be as or more effective. However, of the two, this review is focused on cultural tailoring of interventions and interventions to improve cultural competence of patient/provider interactions. The latter were operationalized as studies that intervened at the level of the patient's relationship to the health care system, as opposed to disease treatment/management.
Another limitation is that a number of studies of interventions to improve cultural competence in patient/provider interactions are based on conceptual frameworks drawn from social science literature from various disciplines. While the interventions may indeed have been consistent with cultural competency models, study authors may or may not have intended the interventions be evaluated as cultural competence.
Conclusions
The results of the search show a patchy literature set that highlights the intrapopulation diversity subsumed under the racial and ethnic minority umbrella terminology. The literature also fails to recognize the intersections of racial and ethnic minority populations with other populations experiencing health care disparities. The broader concept of diversity competence may be more appropriate for many people at these intersections. Further discussion of population intersectionality and alternative constructions of cultural competence that address structural inequities can be found in Chapter 5. None of the included studies measured the effect of cultural competence interventions on health care disparities. 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.
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