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Archived: This report is greater than 3 years old. Findings may be used for research purposes, but should not be considered current.

Background and Objectives for the Systematic Review

Reducing health disparities and achieving equitable health care remains an important goal for the U.S. healthcare system. Cultural competence is widely seen as a foundational pillar for reducing disparities through culturally sensitive and unbiased quality care. Culturally competent care is defined as care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors. ¹ The Office of Minority Health, Department of Health and Human Services, established national standards for culturally and linguistically appropriate services in health and health care (National CLAS Standards) to provide a blueprint to implement such appropriate services to improve health care in the U.S. ² The standards cover areas such as governance, leadership, workforce; communication and language assistance; organizational engagement, continuous improvement, and accountability.

A lack of conceptual clarity around cultural competence persists in the field and the research community. There is confusion about what cultural competence means, and different ways in which it is conceptualized and operationalized. This confusion leads to disagreement regarding the topic areas and practices in which a provider should train to attain cultural competence. ³ The populations to which the term cultural competence applies are also ill-defined. Cultural competence is often seen as encompassing only racial and ethnic differences, omitting other marginalized population groups who are ethnically and racially similar to a provider but who are at risk for stigmatization or discrimination, are different in other identities, or have differences in healthcare needs that result in health disparities. This broader concept may be termed diversity competence. In keeping with this broader view and AHRQ's commitment to a comprehensive approach to priority populations, this systematic literature review considers, alongside race and ethnicity, two of these less considered populations: persons with disabilities and persons identifying as lesbian, gay, bisexual, transgender, queer/questioning, and/or intersex (LGBTQI).

The most popular and most well studied type of cultural competence intervention is cultural competency training for healthcare providers. Two general approaches have been used in creating educational interventions to address cultural competence: programs aimed at improving knowledge that is group-specific, and programs that apply generic or universal models. Concerns have been raised about cultural competency programs that use a group-specific approach to teach providers about the attitudes, values, and beliefs of a specific cultural group leading to stereotyping and oversimplifying the diversity within a particular priority group. ⁴ The universal approach to training proposes that cultural competence can be taught through reflective awareness, empathy, active listening techniques, and the cognitive mechanisms contributing to cultural insensitivity or blindness, such as implicit biases or stereotype threats. Therefore, of interest is identifying the effect of varying types of cultural competence training on patient-level outcomes.

In addition to education and training, changing clinical environments can also be key to purposeful change in behavior. The National CLAS includes several standards that address the organizational level rather than the patient/provider relationship. ¹ Changes in provider knowledge, attitudes, and skills is a necessary step, but for those gains to translate into culturally competent behaviors there also needs to be changes in the structures and culture of health care systems and organizations. This review is intended to focus on the effectiveness of interventions and the provider and system level, but not at the level of policy which, while important, is beyond the scope of this review.

What outcomes are considered high priority and final patient-centered outcomes differ by priority population. For example, while access is important to all priority populations, people from the disability culture may face multiple levels or forms of access barriers, such as transportation to facilities and whether the exam room and its contents is physically accessible. Similarly, linguistic competence means something different to a provider treating a person for whom English is a second language than to a provider treating a transgendered person.

Comparative effectiveness reviews evaluate the evidence for both benefits and harms, or adverse effects, of interventions in order to provide decisionmakers with the balance of net benefits. In the case of cultural competence interventions, harms may include unintended consequences of an intervention. For example, while cultural competence interventions often aim to improve cultural sensitivity by reducing stereotyping and stigma, there remains the possibility that some interventions may inadvertently induce different stereotyping behaviors by inducing a provider to create new scripts, or ways of categorizing people, that result in negative consequences.

The review was requested by Senior Advisors in AHRQ's Division of Priority Populations. The request originally derived from general concerns regarding pervasive disparities in care for adults and children that may be associated with gender, disability and race/ethnicity. In addition, the consideration of cultural competence is usually focused on racial or ethnic minority adults, thus creating a gap in evidence-based information in racial or ethnic minority children, persons with disabilities, and LGBTQI people. This systematic literature review will consider the effect of cultural and diversity competence interventions on three populations with varying degrees of cultural identification and visibility: LGBTQI adolescents and adults, children and adults aging with disabilities, and racial/ethnic minority children and adults.

As noted previously, cultural competence is challenging to isolate as a concept. The concept of cultural competence overlaps with several other concepts related to providing high-quality, appropriate care. Figure 1 provides an illustration of a few of these overlapping concepts. When conducting systematic review, clarity in discriminating between interventions within the scope of cultural competence versus those outside is important. The review's main focus is on whether cultural competency interventions change the clinicians' behaviors (such as communication and clinical decisionmaking), the patient-provider relationship, and/or clinical systems to result in better outcomes for patients from the priority populations. Some public health outreach activities, (such as community-based HIV education in underserved, African American neighborhoods or school-based empowerment programs for young people with disabilities), may address an unmet need. However, such studies will not be included in this review, as our focus is on the patient-provider interaction and the system of care surrounding that interaction. Within the clinical context, interventions aimed at improving care for all patients (such as patient-centered care, patient-centered medical home, health literacy), are excluded unless the intervention is specifically tailored to one of the populations of interest in this review. Because patients are also participants in the system, interventions at the provider or system level that help patients competently navigate the patient-provider relationship and/or the health system are also of interest. This review is focused on interventions that promote equity, the primary outcomes of interest are reductions in disparities between populations for a given health outcome measure.

Figure 1. Health services research concepts that overlap with cultural competence

Includable interventions that lie within the Cultural Competence circle in Figure 1 are defined as:

"People first" care interventions that promote "individuation." These interventions prompt providers to make a conscious effort to view people in terms of their individual characteristics rather than group membership, and being aware of one's own biases and stereotypes. The interventions can also take place at the system level, engineering a system that promotes providing needed care universally, such as equitable receipt of preventive or chronic disease management.

Cultural competence interventions that improve the ability of providers to provide health care services to patients who are unlike the providers (or the providers' culture) in important ways. Targeted providers in such cases can include physicians, nursing staff, allied health professionals, paraprofessionals, and clinic staff who have regular contact with patients, or health system factors intended to engineer the system to support and sustain cultural competence.

Interventions that assist patients from priority populations to competently navigate the patient-provider relationship and the larger health system

Interventions that address physical barriers to access.

Interventions that educate providers about, and to look for, the common secondary conditions specific to the target populations. For example, people with disabilities commonly experience an identifiable set of health conditions secondary to the disability such as urinary tract infections, asthma, obesity, hypertension, and pressure ulcers.⁵

As the overlapping circles in Figure 1 suggest, there are also interventions encompassed in meeting underserved needs that are not within the scope of this review, such as interventions to address access problems due to finance/insurance coverage issue (such as Medicare/Medicaid), and general health literacy interventions.

Key Questions

Key questions, PICOT, and analytic framework were posted for public comment from February 6, 2014 to February 26, 2014. In response to comments provided, we made several changes. Outcomes of interest were expanded and specified for each priority population. Young adults/transitional aged youth were added to the LGBTQI population as a subgroup of interest. Key Question 5 was rewritten to better fit systematic review methods focused on interventions targeted at the organization and structure level, which can include the built environment.

Question 1

What models have been used to conceptualize cultural competence and culturally appropriate care in health contexts, and how do those models compare?

Question 2

What is the effectiveness of interventions to improve culturally appropriate care for LGBTQI adolescents (ages 13-17), young adult (18-25), and adults?

A. Provider intermediate outcomes

Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes

Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization

Improved specific knowledge of health needs unique to LGBTQI community

Provider behavior, such as clinical decision-making, communication

B. Patient intermediate outcomes

Patient learning/knowledge, including linguistic competence regarding gender-diversity

Improved access to health services

Utilization of health services

Patient experience and satisfaction, such as improved perceptions of care

Patient health behaviors, such as tobacco use or health seeking behaviors

Use of preventive services

C. Final health or patient-centered health outcomes, including but not limited to:

Improved mental health outcomes, such as depression, anxiety, suicidality, peer/familial/intimate relationships, substance use

Improved medical health outcomes, such as reduction in obesity, improved sexual health

Adverse events; unintended negative consequences of intervention

Question 3

What is the effectiveness of interventions to improve culturally appropriate health care for children and adults with disabilities?

A. Provider intermediate outcomes

Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes, willingness to serve and perceived competence in service people with disabilities

Provider behavior, such as clinical decision-making, communication

Provider beliefs/cognitions the priority population, such as reducing stereotyping and stigmatization

B. Patient intermediate outcomes

Improved access to health services

Utilization of health services

Patient experience and satisfaction, such as improved perceptions of care

C. Final health or patient-centered health outcomes, including but not limited to:

Improved mental health outcomes, such as depression, substance use

Improved medical health outcomes, such as reduction in obesity, metabolic disorders, heart disease, breast cancer

Patient health behaviors, such as tobacco use or health seeking behaviors

Use of preventive services, and other access to care measures

D. Adverse effects; unintended negative consequences of interventions

Question 4

What is the effectiveness of interventions to improve culturally appropriate health care for racial/ethnic minority children and adults?

A. Provider intermediate outcomes

Provider training and motivation outcomes, such as post-test competencies, knowledge, changes in attitudes, willingness to serve and perceived competence in service people with disabilities

Provider behavior, such as clinical decision-making, communication

Provider beliefs/cognitions about the priority population, such as reducing stereotyping and stigmatization

B. Patient intermediate outcomes

Patient beliefs/attitudes such as improved trust, perceived racism

Utilization of health services

Patient experience and satisfaction, such as improved perceptions of care

Patient health behaviors, such as tobacco use or health seeking behaviors

Use of preventive services, and other access to care measures

C. Final health or patient-centered health outcomes, including but not limited to:

Improved mental health outcomes, such as depression, substance use

Improved medical health outcomes, such as reduction in obesity, kidney disease, heart disease, breast cancer, sickle cell disease

D. Adverse effects; unintended negative consequences of interventions

Question 5

What is the effectiveness of organizational or structural interventions for promoting culturally appropriate care for each of the priority populations across providers?

PICOTS

Intervention

Cultural competence/ culturally appropriate care provider education and training

Cultural competence/ culturally appropriate care clinic-based interventions targeted to patients

Cultural competence/ culturally appropriate care clinic-based interventions targeted to providers

Same as KQ2

Same as KQ2

Cultural competence/ culturally appropriate care interventions targeted at the organizational level, including physical/ environmental factors.

Comparator groups

Usual care

Head-to-head trials of different strategies

Same as KQ2

Same as KQ2

Same as KQ2

Outcomes

Intermediate outcomes

Provider training and motivation outcomes (competencies, knowledge, changes in attitudes)

Provider behavior, such as clinical decision-making, communication

Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization

Provider improved specific knowledge of health needs unique to LGBT community

Patient learning/ knowledge

Utilization of health services

Patient experience/ satisfaction

Patient health behaviors

Use of preventive services and other access to care measures

Final health or patient-centered outcomes - reduced disparities in terms of:

Patient medical care outcomes

Patient mental health care outcomes (depression, anxiety, suicidality, substance use, peer/familial/ intimate relationships)

Adverse effects of intervention(s)

Unintended negative consequences of intervention

Intermediate outcomes

Provider training and motivation outcomes (competencies, knowledge, changes in attitudes)

Provider behavior, such as clinical decision-making, communication

Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization

Improved access to health services

Utilization of health services

Patient experience/satisfaction

Final health or patient-centered outcomes - reduced disparities in terms of:

Patient medical care outcomes

Patient mental health care outcomes (depression, substance use)

Patient health behaviors

Use of preventive services and other access to care measures

Adverse effects of intervention(s)

Unintended negative consequences of intervention

Intermediate outcomes

Provider knowledge, attitudes, and competencies (skills) in providing culturally competent health care

Provider behavior, such as clinical decision-making, communication

Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization

Patient beliefs/cognitions such as improved trust, perceived racism

Improved access to health services

Utilization of health services

Patient experience/satisfaction

Patient health behaviors

Use of preventive services and other access to care measures

Final health or patient-centered outcomes - reduced disparities in terms of:

Patient medical care outcomes

Patient mental health care outcomes (depression, substance use)

Adverse effects of intervention(s)

Unintended negative consequences of intervention

Intermediate organizational adaptation outcomes

Process measures

Availability of culturally competent health care across population groups

Structural changes

Analytic Framework

Figure 2. Analytic framework for improving cultural competence to reduce disparities in priority populations

NOTE: Details of specific outcomes for a specific priority population can be found in Table 1.

Methods

A. Criteria for Inclusion/Exclusion of Studies in the Review

Studies will be included in the review based on the PICOTS framework outlined in Table 1 and the study-specific inclusion criteria described in Table 2.

Study Enrollment

Studies of any of the priority populations; LGBTQI, disability, race/ethnic groups

Studies examining interventions to improve gender sensitivity that is, women as a population, rather than the listed priority populations, will be excluded.

Study Design and Quality

Systematic reviews, RCTs, nonrandomized controlled trials, and prospective and retrospective cohort studies with comparators, before/after case reports with comparators, and interrupted time series will be included for each population and treatment option.

Studies specifically addressing treatment harms may also include retrospective and case series designs.

Systematic reviews must include risk of bias assessment with validated tools.

Includable models

Structured depiction of factors or components that describe cultural competence defined as "as care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors."

We will exclude models at organizational or system level that do not suggest possible points of intervention.

Time of Publication

Search all literature 1990 forward. Cultural competence as a concept and concerned gained traction in the published literature during the early 1990s.

Publication type

Published in peer reviewed journals, grey literature sourced from governmental or research organizations

Language of Publication

English

B. Searching for the Evidence: Literature Search Strategies for Identification of Relevant Studies to Answer the Key Questions

We will search Ovid Medline, Ovid PsycInfo, and the Cochrane EPOC to identify previous studies published and indexed in bibliographic databases from 1990 forward. Our search strategy, which appears in Appendix A, was created by staff and a biomedical librarian, and reviewed by a second independent librarian. Our search strategy included relevant medical subject headings and natural language terms for each of the priority populations and the concept of cultural competence. The concept terms were combined with filters to select relevant RCTs, observational studies, and systematic reviews.

Given the lack of specific and agreed-upon terms that capture cultural competence and the priority populations, and the diffused state of the literature, we will approach the search process strategically, using both inductive and deductive approaches. We will examine the LGBT literature first as a relatively easier priority group but one that does not necessarily refer to itself as a "culture" to define through keyword searches for lessons learned regarding natural language use that may help with capturing disability populations not otherwise easily identifiable as a "culture." Likewise, identified relevant LGBT cultural competence literature may also serve to help identify extensions of natural language terms for keyword search terms to use for cultural competence in the disability literature. Much of the cultural competence literature grew out of concern for the racial/ethnic implications and the terms used for racial/ethnic groups do not translate well to other priority groups that do not necessarily self-identify as a culture. We will also iteratively return to bibliographic databases to search the literature as new terms are uncovered or new relevant interventional approaches are discovered.

As bibliographic database searches are completed for each priority group, we will review the search results for studies relevant to our PICOTS framework and study-specific criteria. The literature set identified at this phase will be examined from a content analysis perspective for emerging themes. Focused searches will then be developed to specifically search for further examples of that intervention theme in the literature.

Search results will be downloaded to EndNote. ⁶ Titles and abstracts will be reviewed by two independent investigators to identify studies meeting PICOTS framework and inclusion/exclusion criteria. All studies identified as relevant by either investigator will undergo full-text screening. Two investigators will independently screen full text to determine if inclusion criteria are met. Differences in screening decisions will be resolved by consultation between investigators, and, if necessary, consultation with a third investigator. We will document the inclusion and exclusion status of citations undergoing full-text screening. Throughout the screening process, team members will meet regularly to discuss training material and issues as they arise to ensure consistency of inclusion criteria application.

Bibliographic database searches will be supplemented with backward citation searches of highly relevant systematic reviews. We will also share search results with the TEP for ask for themes which may have been missed in the initial searches. We will update searches while the draft report is under public/peer review.

We will conduct additional grey literature searching to identify other search efforts into the priority populations or cultural competence for further MeSH or natural language keyword search terms. Relevant grey literature resources include trial registries and governmental or research organizations. We will search ClinicalTrials.gov and HSRProj for ongoing or completed studies.

C. Data Abstraction and Data Management

Studies meeting inclusion criteria will be distributed among investigators for data extraction. One investigator will extract relevant study, population demographics, and outcomes data. Data fields to be extracted will be determined based upon proposed summary analysis. These fields will include author, year of publication; setting, author definition of cultural competence, subject inclusion and exclusion criteria, intervention and control characteristics (intervention definition and components, timing, frequency, duration, fidelity), followup duration, participant baseline demographics, enrollment, descriptions and results of primary outcomes and adverse effects, and study funding source. Relevant data will be extracted into extraction forms created in Excel. Evidence tables will be reviewed and verified for accuracy by a second investigator.

We will use data from relevant comparisons in previous systematic reviews to replace the de novo extraction process when the comparison is sufficiently relevant. Data elements abstracted from included systematic reviews, whether the elements are at the individual study or systematic review levels, will depend on how the systematic review will be used. Use may range using individual elements to updating a review, to using the review without modification. Only systematic reviews that assess included study risk of bias will be assessed for review quality. Systematic reviews with fair or good methodology will be used. Systematic reviews that are deemed to have potential author conflict of interest, such as due to reviewing a body of literature to which the authors had substantially contributed, will be subjected to random quality checks of 10 percent of included study data abstraction. RCTs in included systematic reviews will be tracked for contribution to unique population/treatment/outcome comparisons to avoid double-counting study results.

D. Assessment of Methodological Risk of Bias of Individual Studies

Risk of bias of eligible studies will be assessed using instruments specific to study design. For RCTs, questionnaires developed from the Cochrane Risk of Bias tool will be used. The seven domains included in this tool include sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data (i.e., was incomplete outcome data adequately addressed), selective reporting, and other sources of bias (i.e., problems not covered by other domains). Additional items will be developed to assess potential risk-of-bias not addressed by the Cochrane tool. Outcomes measurement issues inherent in the psychometric properties of the questionnaires used to measure outcomes and assessment methods used to detect change in those questionnaire results will be specifically evaluated for detection bias. Additional items may be necessary to evaluate potential risk-of-bias associated with treatment definition and implementation (treatment fidelity). Specific study methodology or conduct will be used to judge potential risk of bias with respect to each domain following guidance in the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0. ⁷

We developed an instrument for assessing risk of bias for observational studies based on the RTI Observational Studies Risk of Bias and Precision Item Bank. ⁸ We selected items most relevant in assessing risk of bias for this topic, including participant selection; attrition, ascertainment, and appropriateness of analytic methods. The preliminary risk of bias assessment form is provided in Appendix B. The form will be tested by investigators, with particular attention to project term definitions, using an initial sample of included studies and will be finalized by full team input.

Two investigators will independently assess risk of bias for all included studies. Investigators will consult to reconcile any discrepancies in overall risk of bias assessments. Overall summary risk of bias assessments for each study will be classified as low, moderate, or high based upon the collective risk of bias inherent in each domain and confidence that the results are believable given the study's limitations. When the two investigators disagree, a third party will be consulted to reconcile the summary judgment. Outcomes in studies assessed as having a high risk of bias will be compared to synthesized evidence as a means of sensitivity analysis. Contradictions will be investigated in further depth.

Systematic review quality and risk of bias will be assessed using modified AMSTAR criteria. ⁹ Study-level risk of bias must be assessed using validated risk of bias tools appropriate to study design. Since AMSTAR was not originally created as a quality review tool, an additional question regarding whether the review findings logically follow from the contributing studies will be added.

E. Data Synthesis

We will summarize the results into evidence tables and synthesize evidence for each unique population, comparison, and outcome combination. When a comparison is adequately addressed by a previous systematic review of acceptable quality and no new studies are available, we will reiterate the conclusions drawn from that review. When new trials are available, previous systematic review data will be synthesized with data from additional trials.

We will summarize included study characteristics and outcomes in evidence tables. We do not expect pooling to be appropriate due to lack of comparable studies or heterogeneity; qualitative synthesis will be conducted in these instances. Observational literature examining treatment benefits will be used for subgroups not covered by published RCTs. We will treat cultural tailoring/targeting studies as a separate literature group that provides context for or informs current or possible future cultural competence intervention research.

The following matrixes provide a basic framework by which intervention population targets and general categories of measures may be assessed. Each of the cells may be exploded into another matrix of relevant details. Likewise, each of the outcome categories listed here may be exploded for finer detail. For example, we will distinguish between medical and mental health services, for patient intermediate outcomes. Provider types, if information is available in the literature, may be another useful way to contrast information, particularly for ethnicity- or gender-based care providers. Individual provider versus team approaches will be examined separately. We will also differentiate between models for undergraduate and graduate medical and health care education as compared to "re-training" existing providers.

We will explore second order interactions if literature is identified allowing such examination. For example, we will look for intersections of disability and race, or LGBT and race, or LGBT and disability priority populations. We will also separate analyses by subgroups within the priority populations, such as different LGBT identities, if the literature provides such information.

Should there be sufficient literature available for possible pooling, decisions for pooling will be based on the homogeneity of study populations based on inclusion criteria, specific interventions, and the ability to treat outcome measures as similar. Data will be analyzed in RevMan 5.21 ¹⁰ software. Observational literature examining treatment benefits will be used for subgroups not covered by published RCTs. Using a random effects model, we will calculate risk ratios (RR) and absolute risk differences (RD) with the corresponding 95 percent confidence intervals (CI) for binary primary outcomes. Weighted mean differences (WMD) and/or standardized mean differences (SMD) with the corresponding 95 percent CIs will be calculated for continuous outcomes. We will assess the clinical and methodological heterogeneity and variation in effect size to determine appropriateness of pooling data. ¹¹ If data are appropriate for pooling, meta-analysis will be performed. We will assess statistical heterogeneity with Cochran's Q test and measure magnitude with I ² statistic. ¹¹

For KQ 1, we will compare model characteristics. The results of this comparison may be used to organize results for KQ2-5.

F. Grading the Strength of Evidence (SOE) for Major Comparisons and Outcomes

The overall strength of evidence for primary outcomes of KQ2-5 within each comparison will be evaluated based on four required domains: (1) study limitations (risk of bias); (2) directness (single, direct link between intervention and outcome); (3) consistency (similarity of effect direction and size); and (4) precision (degree of certainty around an estimate). ¹² A fifth domain, reporting bias, will be assessed when SOE based upon the first four domains is moderate or high. ¹² Based on study design and conduct, risk of bias will be rated as low, medium, or high. Consistency will be rated as consistent, inconsistent, or unknown/not applicable (e.g., single study) based on the direction, magnitude, and statistical significance of all studies. Directness will be rated as either direct or indirect based on the need for indirect comparisons when inference requires observations across studies. Precision will be rated as precise or imprecise based on the degree of certainty surrounding each effect estimate or qualitative finding. An imprecise estimate is one for which the confidence interval is wide enough to include clinically distinct conclusions. Other factors that may be considered in assessing strength of evidence include dose-response relationship, the presence of confounders, and strength of association. Based on these factors, the overall strength of evidence for each outcome will be rated as: ¹²

High: Very confident that estimate of effect lies close to true effect. Few or no deficiencies in body of evidence, findings believed to be stable.

Moderate: Moderately confidence that estimate of effect lies close to true effect. Some deficiencies in body of evidence; findings likely to be stable, but some doubt.

Low: Limited confidence that estimate of effect lies close to true effect; major or numerous deficiencies in body of evidence. Additional evidence necessary before concluding that findings are stable or that estimate of effect is close to true effect.

Insufficient: No evidence, unable to estimate an effect, or no confidence in estimate of effect. No evidence is available or the body of evidence precludes judgment.

We will assess strength of evidence for published systematic reviews replacing de novo review processes that did not provide a strength of evidence assessment based on a GRADE or GRADE-equivalent method.

We will assess strength of evidence for outcomes drawn from more than one study for a given patient population/intervention/outcome comparison. For outcomes drawn from a single study, given the low probability that such a study is of large sample size, we will only assess strength of evidence for studies of low risk of bias. Results and risk of bias will be presented for other reported included studies to provide information across the full spectrum of included studies. However, results of studies not undergoing strength of evidence assessment will be identified as hypothesis generating, rather than hypothesis testing, in nature.

G. Assessing Applicability

Cultural competence intervention research by definition generally draws on defined priority populations, and very possibly specific subgroups of those priority populations. To the extent that similar interventions are tested in multiple studies across priority population groups, we will be able to suggest generalizability across those groups. Otherwise generalizability will be narrowly subscribed by the study populations. Applicability of studies will be determined according to the PICOTS framework. Study characteristics that may affect applicability include, but are not limited to, the population from which the study participants are enrolled, and patient or intervention characteristics different than those described by population studies of the priority populations or types of organizational settings. We will pay special attention to defined subgroups that are at the intersections of two or more priority populations. These applicability issues are present in the synthesis frameworks and sensitivity analyses described in more detail in the data synthesis section.

References

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2. Office of Minority Health, U.S. Department of Health and Human Services. The National CLAS Standards. Last Accessed May 29, 2013.

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4. Betancourt, Joseph R. MD, MPH; Green, Alexander R. MD, MPH. Commentary: Linking Cultural Competence Training to Improved Health Outcomes: Perspectives From the Field. Academic Medicine Issue: Volume 85(4), April 2010, pp 583-585

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8. Viswanathan M, Berkman ND. Development of the RTI item bank on risk of bias and precision of observational studies. Journal of Clinical Epidemiology. 2011.

9. White C, Ip S, McPheeters M, et al. Using existing systematic reviews to replace de novo processes in conducting Comparative Effectiveness Reviews Agency for Healthcare Research and Quality. Rockville, MD: 2009.

10. Review Manager (RevMan) [Computer program]. Version 5.2. Copenhagen: The Nordic Cochrane Centre TCC, 2012.

11. Fu R, Gartlehner G, Grant M, et al. Conducting quantitative synthesis when comparing medical interventions: AHRQ and the Effective Health Care Program. Journal of Clinical Epidemiology. 2011 Nov;64(11):1187-97. PMID 21477993.

12. Methods Guide for Comparative Effectiveness Reviews. AHRQ Publication No. 13(14)-EHC 130-EF, Grading the strength of a body of evidence when assessing health care interventions for the effective health care program of the Agency for Healthcare Research and Quality: An update. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

Definition of Terms

Not applicable.

Summary of Protocol Amendments

If we need to amend this protocol, we will give the date of each amendment, describe the change and give the rationale in this section. Changes will not be incorporated into the protocol.

Review of Key Questions

AHRQ posted the key questions on the Effective Health Care Website for public comment. The EPC refined and finalized the key questions after review of the public comments, and input from Key Informants and the Technical Expert Panel (TEP). This input is intended to ensure that the key questions are specific and relevant.

Key Informants

Key informants are the end users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Within the EPC program, the key informant role is to provide input into identifying the Key Questions for research that will inform healthcare decisions. The EPC solicits input from key informants when developing questions for systematic review or when identifying high priority research gaps and needed new research. Key informants are not involved in analyzing the evidence or writing the report and have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.

Key informants must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their role as end-users, individuals are invited to serve as key informants and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Technical Experts

Technical experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicting opinions are common and perceived as health scientific discourse that results in a thoughtful, relevant systematic review. Therefore study questions, design, and methodological approaches do not necessarily represent the views of individual technical and content experts. Technical experts provide information to the EPC to identify literature search strategies and recommend approaches to specific issues as requested by the EPC. Technical experts do not do analysis of any kind nor do they contribute to the writing of the report. They have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism.

Technical experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as technical experts and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Peer Reviewers

Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodological expertise. The EPC considers all peer review comments on the draft report in preparation of the final report. Peer reviewers do not participate in writing or editing of the final report or other products. The final report does not necessarily represent the views of individual reviewers. The EPC will complete a disposition of all peer review comments. The disposition of comments for systematic reviews and technical briefs will be published three months after the publication of the evidence report.

Potential peer reviewers must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Invited peer reviewers may not have any financial conflict of interest greater than $10,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.

EPC Team Disclosures

EPC core team members must disclose any financial conflicts of interest greater than $1,000 and any other relevant business or professional conflicts of interest. Related financial conflicts of interest that cumulatively total greater than $1,000 will usually disqualify EPC core team investigators.

Role of the Funder

This project was funded under Contract No. xxx-xxx from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The Task Order Officer reviewed contract deliverables for adherence to contract requirements and quality. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Appendixes

Appendix A. Search algorithms for Cultural Competence

KQ2 Study Filters and LGBT Population Terms

Lines 1-32 Filter for systematic reviews

Lines 33-61 Filter for controlled trials

Lines 62-75 Filter for observational studies, including training/education programs

Lines 76-88 Population terms

Lines 98-100 Intervention terms (used to limit observational studies)

KQ3 Study Filters, Disability Population Terms, and Cultural Competence Terms

Lines 1-32 Filter for systematic reviews

Lines 33-61 Filter for controlled trials

Lines 62-67 Filter for observational studies

Lines 68-81 Population terms

Lines 91-93 Intervention terms

Lines 97-121 Cultural competence in its many forms and targets

KQ4 Study Filters, Racial Ethnic Population Terms, and Cultural Competence

Lines 1-32 Filter for systematic reviews

Lines 33-61 Filter for controlled trials

Lines 62-67 Filter for observational studies

Lines 68-73 Population terms

Lines 83-85 Intervention terms

Lines 89-113 Cultural competence in its many forms and targets

Line 118 To further restrict observational studies

Mixed

Studies in which one group is studied prospectively and the other retrospectively.

Retrospective

Analyzes data from past records.

Partially

Some of the above features.

No

None of the above features.

Partially

Some of the above features
(partially validated scale)

No

None of the above features (self-report, scales with lower validity, reliability); not equivalent across groups

Uncertain

Could not be ascertained.

Uncertain

Could not be ascertained.

Uncertain

Could not be ascertained (i.e. retrospective designs where eligible at baseline could not be determined)

No

Not all prespecified outcomes reported, subscales not prespecified reported, outcomes reported incompletely.

Uncertain

Could not be ascertained.

Yes

Who provided funding?

Overall Risk of Bias Assessment

Low

Results are believable taking study limitations into consideration

Moderate

Results are probably believable taking study limitations into consideration

High

Results are uncertain taking study limitations into consideration

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Improving Cultural Competence to Reduce Health Disparities for Priority Populations

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Reducing health disparities and achieving equitable health care remains an important goal for the U.S. healthcare system. Cultural competence is widely seen as a foundational pillar for reducing disparities through culturally sensitive and unbiased quality care.

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Cultural Competence for Healthcare Providers

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Home &rtrif; Cultural Competence in Health Care: Is it important for people with chronic conditions?

Visit profiles to view data profiles and issue briefs from the series Challenges for the 21st Century: Chronic and Disabling Conditions as well as data profiles on young retirees and older workers.

The increasing diversity of the nation brings opportunities and challenges for health care providers, health care systems, and policy makers to create and deliver culturally competent services. Cultural competence is defined as the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients.(1) A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities. Examples of strategies to move the health care system towards these goals include providing relevant training on cultural competence and cross-cultural issues to health professionals and creating policies that reduce administrative and linguistic barriers to patient care.

Racial and ethnic minorities are disproportionately burdened by chronic illness

Racial and ethnic minorities have higher morbidity and mortality from chronic diseases. The consequences can range from greater financial burden to higher activity limitations.

Among older adults, a higher proportion of African Americans and Latinos, compared to Whites, report that they have at least one of seven chronic conditions - asthma, cancer, heart disease, diabetes, high blood pressure, obesity, or anxiety/ depression.(2) These rank among the most costly medical conditions in America.(3)

African Americans and American Indians/Alaska Natives are more likely to be limited in an activity (e.g., work, walking, bathing, or dressing) due to chronic conditions.(4)

The population at risk for chronic conditions will become more diverse

Although chronic illnesses or disabili- ties may occur at any age, the likelihood that a person will experience any activity limitation due to a chronic condition increases with age.(5) In 2000, 35 million people - more than 12 percent of the total population - were 65 years or older.(6) By 2050, it is expected that one in five Americans - 20 percent - will be elderly. The population will also become increasingly diverse (see Figure 2). By 2050, racial and ethnic minorities will comprise 35 percent of the over 65 pop-ulation.(7) As the population at risk of chronic conditions becomes increasingly diverse, more attention to linguistic and cultural barriers to care will be necessary.

Access to health care differs by race and ethnicity

Having a regular doctor or a usual source of care facilitates the process of obtaining health care when it is needed. People who do not have a regular doctor or health care provider are less likely to obtain preventive services, or diagnosis, treatment, and management of chronic conditions. Health insurance coverage is also an important determinant of access to health care. Higher proportions of minorities compared to Whites do not have a usual source of care and do not have health insurance (see Figures 3A and 3B).

Language and communication barriers are problematic

Of the more than 37 million adults in the U.S. who speak a language other than English, some 18 million people - 48 percent - report that they speak English less than "very well."(8) Language and communication barriers can affect the amount and quality of health care received. For example, Spanish-speaking Latinos are less likely than Whites to visit a physician or mental health provider, or receive preventive care, such as a mammography exam or influenza vaccination.(9) Health service use may also be affected by the availability of interpreters. Among non-English speakers who needed an interpreter during a health care visit, less than half - 48 percent - report that they always or usually had one.(10)

Language and communication problems may also lead to patient dissatisfaction, poor comprehension and adherence, and lower quality of care. Spanish-speaking Latinos are less satisfied with the care they receive and more likely to report overall problems with health care than are English speakers.(11) The type of interpretation service provided to patients is an important factor in the level of satisfaction. In a study comparing various methods of interpretation, patients who use professional interpreters are equally as satisfied with the overall health care visit as patients who use bilingual providers. Patients who use family interpreters or non-professional interpreters, such as nurses, clerks, and technicians are less satisfied with their visit.(12)

Low literacy also affects access to health care

The 1992 National Adult Literacy Survey found that 40 to 44 million Americans do not have the necessary literacy skills for daily functioning.(13) The elderly typically have lower levels of literacy, and have had less access to formal education than younger populations.(14) Older patients with chronic diseases may need to make multiple and complex decisions about the management of their conditions. Racial and ethnic minorities are also more likely to have lower levels of literacy, often due to cultural and language barriers and differing educational opportunities.(15) Low literacy may affect patients' ability to read and understand instructions on prescription or medicine bottles, health educational materials, and insurance forms, for example. Those with low literacy skills use more health services, and the resulting costs are estimated to be $32 to $58 billion - 3 to 6 percent - in additional health care expenditures.(16)

Lack of cultural competence may lead to patient dissatisfaction

People with chronic conditions require more health services, therefore increasing their interaction with the health care system. If the providers, organizations, and systems are not working together to provide culturally competent care, patients are at higher risk of having negative health consequences, receiving poor quality care, or being dissatisfied with their care. African Americans and other ethnic minorities report less partnership with physicians, less participation in medical decisions, and lower levels of satisfaction with care.(17) The quality of patient-physician interactions is lower among non-White patients, particularly Latinos and Asian Americans. Lower quality patient-physician interactions are associated with lower overall satisfaction with health care.(18)

African Americans, Latinos, and Asian Americans, are more likely than Whites to report that they believe they would have received better care if they had been of a different race or ethnicity (see Figure 4). African Americans are more likely than other minority groups to feel that they were treated disrespectfully during a health care visit (e.g., they were spoken to rudely, talked down to, or ignored). Compared to other minority groups, Asian Americans are least likely to feel that their doctor understood their background and values and are most likely to report that their doctor looked down on them.(19)

WHAT IS CULTURAL COMPETENCE IN HEALTH CARE?

Individual values, beliefs, and behaviors about health and well-being are shaped by various factors such as race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation. Cultural competence in health care is broadly defined as the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the health care system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy. Some common strategies for improving the patient-provider interaction and institutionalizing changes in the health care system include:(20)

1. Provide interpreter services

2. Recruit and retain minority staff

3. Provide training to increase cultural awareness, knowledge, and skills

4. Coordinate with traditional healers

5. Use community health workers

6. Incorporate culture-specific attitudes and values into health promotion tools

7. Include family and community members in health care decision making

8. Locate clinics in geographic areas that are easily accessible for certain populations

9. Expand hours of operation

10. Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials

Cultural competence is an ongoing learning process

In order to increase the cultural competence of the health care delivery system, health professionals must be taught how to provide services in a culturally com-petent manner. Although many different types of training courses have been developed across the country, these efforts have not been standardized or incorpo-rated into training for health profession-als in any consistent manner.(21) Training courses vary greatly in content and teaching method, and may range from three-hour seminars to semester-long academic courses. Important to note, however, is that cultural competence is a process rather than an ultimate goal, and is often developed in stages by building upon previous knowledge and experience.
TRAINING APPROACHES THAT TEACH FACTS ABOUT SPECIFIC GROUPS ARE BEST COMBINED WITH CROSS-CULTURAL SKILL-BASED APPROACHES THAT CAN BE UNIVERSALLY APPLIED
Approaches that focus on increasing knowledge about various groups, typically through a list of common health beliefs, behaviors, and key "dos" and "don'ts," provide a starting point for health pro-fessionals to learn more about the health practices of a particular group. This approach may lead to stereotyping and may ignore variation within a group, however. For example, the assumption that all Latino patients share similar health beliefs and behaviors ignores im-portant differences between and within groups. Latinos could include first-generation immigrants from Guatemala and sixth-generation Mexican Americans in Texas. Even among Mexican Americans, differences such as generation, level of acculturation, citizenship or refugee status, circumstances of immigration, and the proportion of his or her life spent in the U.S. are important to recognize.

It is almost impossible to know everything about every culture. Therefore, training approaches that focus only on facts are limited, and are best combined with approaches that provide skills that are more universal. For example, skills such as communication and medical history-taking techniques can be applied to a wide diversity of clientele. Curiosity, empathy, respect, and humility are some basic attitudes that have the potential to help the clinical relationship and to yield useful information about the patient's individual beliefs and preferences. An approach that focuses on inquiry, reflection, and analysis throughout the care process is most useful for acknowledging that culture is just one of many factors that influence an individual's health beliefs and practices.(22)
GUIDELINES FROM PROFESSIONAL ORGANIZATIONS HELP PROMOTE CULTURAL COMPETENCE
Many professional organizations representing a variety of health professionals, such as physicians, psychologists, social workers, family medicine doctors, and pediatricians have played an active role in promoting culturally competent practices through policies, research, and training efforts. For example, the American Medical Association provides information and resources on policies, publications, curriculum and training materials, and relevant activities of physician associations, medical specialty groups, and state medical societies.(23)

Several organizations have instituted cultural competence guidelines for their memberships. For example, based on ten years of work, the Society of Teachers of Family Medicine has developed guidelines for curriculum material to teach cultural sensitivity and competence to family medicine residents and other health professionals. These guidelines focus on enhancing attitudes in the following areas:(24)

Awareness of the influences that sociocultural factors have on patients, clinicians, and the clinical relationship.

Acceptance of the physician's respon-sibility to understand the cultural aspects of health and illness

Willingness to make clinical settings more accessible to patients

Recognition of personal biases against people of different cultures

Respect and tolerance for cultural differences

Acceptance of the responsibility to combat racism, classism, ageism, sexism, homophobia, and other kinds of biases and discrimination that occur in health care settings.

ACCREDITATION STANDARDS THAT ADDRESS CULTURAL COMPETENCE IN MEDICAL SCHOOLS HAVE THE POTENTIAL TO REACH MANY FUTURE PHYSICIANS
Accreditation standards are important tools that can have widespread effects on the cultural competence of medical students, health care professionals, and health care organizations. For example, the Liaison Committee on Medical Edu-cation (LCME) - the nationally recognized accreditation body for medical schools in the U.S. and Canada - recently mandated higher standards for curriculum material on cultural competence than were previously in place. As a result, medical schools must now provide students with the skills to understand how people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Students must also be able to recognize and appropriately address racial and gender biases in themselves, in others, and in the delivery of health care.(25)

Commitment to cultural competence is growing among health care providers and systems

Health systems are beginning to adopt comprehensive strategies to respond to the needs of racial and ethnic minorities for numerous reasons. First, there are increasingly more state and federal guidelines that encourage or mandate greater responsiveness of health systems to the growing population diversity. Second, these strategies may be seen as essential to meeting the federal government's Healthy People 2010 goal of eliminating racial and ethnic health disparities. Third, many health systems are finding that developing and implementing cultural competence strategies are a good business practice to increase the interest and participation of both providers and patients in their health plans among racial and ethnic minority populations.

In addition to increasing the cultural competence of health care providers, organizational accommodations and policies that reduce administrative and linguistic barriers to health care are also important. Policies that strive to achieve cultural competence throughout the organization must address issues on all levels, from the organization's top management to clinicians to office staff to billing and administrative staff. Organizational policies that address language and literacy barriers have been among the most successful efforts.
BILINGUAL AND BICULTURAL SERVICES ARE EFFECTIVE
Traditionally, community health centers that serve the Asian American or Latino communities have the most fully developed linguistic capabilities. For example, Asian Counseling and Referral Services (ACRS) in Seattle is a community-based mental health organization that effectively addresses language needs. They try to provide bilingual and bicultural clinicians that match the client's background. When this is not possible, ACRS provides trained staff to act as co-providers with a licensed mental health professional. These trained individuals act not only as interpreters, but also help provide a cultural context for the client's beliefs and practices. Stemming from 30 years of experience in this arena, ACRS has developed a training curriculum, "Building Bridges: Mental Health Interpreter Training for Interpreters of Southeast Asian Languages." This curriculum will be used as a model for a national mental health interpreter training project to address the needs of limited-English speaking people. This national project includes training for interpreters, trainers, and health providers, as well as a mental health interpreter certification process.(26)

Within the Latino community, the use of promotoras, also known as peer edu-cators, is becoming increasingly popular. Promotoras are generally ordinary people from hard-to-reach populations who act as bridges between their community and the complicated world of health care. They learn about health care principles from doctors or non-profit groups, and share their knowledge with their com-munities. The peer education model is not only cost-effective, but also has been shown to be more effective in terms of reaching populations who find the information more credible coming from someone with a familiar background.(27)
ASSESSING LITERACY LEVELS CAN BREAK DOWN BARRIERS
Methods employed to assess literacy levels include the use of screening instruments that test for certain skills related to functional literacy or less formal tools that allow health care professionals to determine a person's comfort level with various modes of communication. For example, at the To Help Everyone (T.H.E.) Clinic in Los Angeles, nurses and health care professionals speak individually with patients when they arrive at the health clinic to determine whether the patient prefers to learn by using written materials, pictures, verbal counseling, or some other technique. This method of assessment allows the patient to identify their own learning style preference without having to take a literacy test; it also reduces feelings of fear or humiliation that may occur when singled out.(28)

FEDERAL STANDARDS AND GUIDELINES FOR PROVIDING CULTURALLY AND LINGUISTICALLY APPROPRIATE CARE

1. The Department of Health and Human Services has provided important guidance on how to ensure culturally and linguistically appropriate health care services. The Office for Civil Rights published "Title VI Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency." Very few states have developed standards for linguistic access. States that have developed such standards have focused on managed care organizations, contracting agreements with providers, and specific health and mental health services in defined settings.(29)

2. In August 2000, the Health Care Financing Administration (now Centers for Medicare and Medicaid Services) issued guidance to all state Medicaid directors regarding interpreter and translation services, emphasizing that federal matching funds are available for states to provide oral interpretation and written translation services for Medicaid beneficiaries.(30)

3. In December 2000, the Office of Minority Health of the Department of Health and Human Services issued 14 national standards on culturally and linguistically appropriate services (CLAS) in health care. These standards are intended to correct current inequities in the health services system and to make these services more responsive to the individual needs of all patients. They are designed to be inclusive of all cultures, with a particular focus on the needs of racial, ethnic, and linguistic population groups that experience unequal access to the health care system. The CLAS standards provide consistent definitions of culturally and linguistically appropriate services in health care and offer a framework for the organization and implementation of services. CLAS standards can be found at http://www.omhrc.gov/CLAS/

4. In 2002, two guides were developed to assist managed care plans with cultural and linguisti-cally appropriate services: "Providing Oral Linguistic Services: A Guide for Managed Care Plans" and "Planning Culturally and Linguistically Appropriate Services: A Guide for Managed Care Plans." Both guides can be found at www.cms.gov/healthplans/quality/project03.asp

Conclusion

Cultural competence is not an isolated aspect of medical care, but an important component of overall excellence in health care delivery. Issues of health care quality and satisfaction are of particular concern for people with chronic conditions who frequently come into contact with the health care system. Efforts to improve cultural competence among health care professionals and organizations would contribute to improving the quality of health care for all consumers.

1. Betancourt, J. R., Green, A. R., & Carrillo, J. E. 2002. Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.

2. Collins, K.S., Hughes, D. L., Doty, M. M., Ives, B. L. Edwards, J. N., & Tenney, K. 2002. Diverse communities, common concerns: Assessing health care quality for minority Americans. New York: The Commonwealth Fund.

3. Druss, B.G., Marcus, S.C., Olfson, M., Pincus, H.A. 2002. The most expensive medical conditions in America. Health Affairs, 21, 105-111.

4. Fried, V. M., Prager, K., MacKay, A. P., Xia, H. 2003. Health, United States, 2003: Chartbook on trends in the health of Americans. Hyattsville, MD: National Center for Health Statistics.

5. Ibid.

6. U.S. Bureau of the Census. 2000. Table DP-1, Profile of general demographic characteristics: 2000. Washington, DC: Author. Retrieved November 13, 2003, from http://factfinder.census.gov.

7. Day, J. C. 1996. Population projections of the United States by age, sex, race, and Hispanic origin: 1995 to 2050. (U.S. Bureau of the Census, Current Population Reports, P25-1130). Washington, DC: U.S. Government Printing Office.

8. Center on an Aging Society analysis of data from the 2000 Census, QT-P17, Ability to speak English. Washington, DC: U.S. Bureau of the Census, Census Summary File 3 ? Sample Data.

9. Fiscella, K., Franks, P., Doescher, M. P., & Saver, B. G. 2002. Disparities in health care by race, ethnicity and language among the insured: Findings from a national sample. Medical Care, 40(1), 52-59.

10. Collins et al. 2002.

11. Carrasquillo, O., Orav, E. J., Brennan, T. A., Burstin, H. R. 1999. Impact of language barriers on patient satisfaction in an emergency department. Journal of General Internal Medicine, 14, 82-87.

12. Lee, L. J, Batal, H. A., Maselli, J. H. Kutner, J. S. 2002. Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic. Journal of General Internal Medicine, 17, 641-646.

13. Kirsch, I. S., Jungeblut, A., Jenkins, L., & Kolstad, A. 2002. Adult literacy in America: A first look at the results of the National Adult Literacy Survey, Third Edition. Washington, DC: U.S. Department of Education, National Center for Education Statistics, Office of Educational Research and Improvement. Retrieved November 13, 2003, from http://nces.ed.gov/pubs93/93275.pdf.

14. Cooper, L. A., Roter, D. L. 2003. Patient-provider communication: The effect of race and ethnicity on process and outcomes of healthcare. In B. D. Smedley, A. Y. Stith & A. R. Nelson (Eds.) Unequal treatment: Confronting racial and ethnic disparities in health care (pp. 552-593). Washington, DC: The National Academies Press.

15. Wilson, J.F. 2003. The crucial link between literacy and health. Annals of Internal Medicine, 139, 875-878.

16. Center for Health Care Strategies. 2003. Impact of low health literacy skills on annual health care expenditures. Lawrenceville, NJ: Author. Retrieved November 17, 2003, from http://www.chcs.org/ resource/pdf/h13.pdf.

17. Cooper & Roter. 2003.

18. Saha, S., Arbelaez, J. J., Cooper, L. A. 2003. Patient-physician relationships and racial disparities in the quality of health care. American Journal of Public Health, 93, 1713-1719.

19. Collins et al. 2002.

20. Brach, C. & Fraser, I. 2000. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review, 57 (Supplement 1), 181-217.

21. American Institutes for Research. 2002. Teaching cultural competence in health care: A review of current concepts, policies, and practices. Report prepared for the Office of Minority Health. Washington, DC: Author.

22. Bonder, B., Martin, L., Miracle, A. 2001. Achieving cultural competence: The challenge for clients and healthcare workers in a multicultural society. Generations, 25, 35-42.

23. American Medical Association. 1999. Cultural Competence Compendium. Chicago: Author.

24. American Institutes for Research. 2002.

25. Liaison Committee on Medical Education. 2001. Functions and structure of a medical school. Retrieved February 2, 2004, from http:// www.lcme.org/functions2003september.pdf.

26. Asian Counseling and Referral Service. 2003. ACRS participates in national effort to train mental health interpreters. Seattle, WA: Author. Retrieved November 25, 2003, from http://www.acrs.org/eventsNews/ newsletter.htm

27. Kolker, C. 2004, January 5. "Familiar faces bring health care to Latinos." The Washington Post, p. A03.

28. Kiefer, K. M. 2001. Health literacy: Responding to the need for help. Washington, DC: Center for Medicare Education.

29. Goode, T., Sockalingam, S., Brown, M., & Jones, W. 2001. Linguistic competence in primary health care delivery systems: Implications for policy makers. Washington, DC: National Center for Cultural Competence, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center.

30. Westmoreland, T. M. 2000, August 31. Letter to State Medicaid Directors from Timothy M. Westmoreland, Director, Centers for Medicare and Medicaid Services. Retrieved November 18, 2003, from http:// cms.hhs.gov/states/letters/smd83100.asp.
ABOUT THE ISSUE BRIEFS
This is the fifth in a series of Issue Briefs on Challenges for the 21st Century: Chronic and Disabling Conditions. This series is supported by a grant from the Robert Wood Johnson Foundation. The Issue Briefs accompany the Center's ongoing series of Data Profiles in the same series. Emily Ihara wrote this Issue Brief.

The Center on an Aging Society is a non-partisan policy group located at Georgetown University's Institute for Health Care Research and Policy. The Center studies the impact of demographic changes on public and private institutions and on the financial and health security of families and people of all ages.

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Cultural Competence in Health Care: Is it important for people with chronic conditions? - Health Policy Institute

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Visit profiles to view data profiles and issue briefs from the series Challenges for the 21st Century: Chronic and Disabling Conditions as well as data profiles on young retirees and older workers. The increasing diversity of the nation brings opportunities and challenges for health care providers, health care systems, and policy makers to create and [...]

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What is Cultural Competency in Healthcare?