CDE Appendix 1 Literature Review - Central East Local Health ...

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The Culture, Diversity and Equity Project: Literature Review • Epidemiology of specific health and health-care disparities; • Factors underlying health and health-care disparities—access, socioeconomic, environment, institutional, racial/ethnic; • Demographic patterns of health-care disparities, both local and national; and • Collaborating with communities to eliminate disparities—through community experiences. • Domain V: Cross-Cultural Clinical Skills • Knowledge, respect, and validation of differing values, cultures, and beliefs, including sexual orientation, gender, age, race, ethnicity, and class; • Dealing with hostility/discomfort as a result of cultural discord; • Eliciting a culturally valid social and medical history; • Communication, interaction, and interviewing skills; • Understanding language barriers and working with interpreters; • Negotiating and problem-solving skills; and • Diagnosis, management, and patient-adherence skills leading to patient compliance (AAMC, 2005, p. 9). 2. Specific Components Grid The second part (Specific Components) of the TACTT identifies and details the specific knowledge (K), skills (S), and attitudes (A) that need to be taught and evaluated for, under each of these five domains. 5.3. LIMITATIONS OF THE TRAINING LITERATURE, FRAMEWORKS & STANDARDS (1) Lack of evidence-base and quality evaluation One of the greatest limitations of the existing cultural competence training literature is the lack of empirical data concerning what makes diversity training, and linguistically and culturally appropriate health education training in particular, effective (Curtis et al., 2007; Anderson et al., 2003). Much of this has to do with the poor methodological design and/or rigour of the few evaluations in the literature that do examine the impact of cultural competence training on minority health care quality (Beach et al., 2005; Beach et al, 2006; and Curtis et al., 2007). Most such studies, for instance, rely on self-administered tools for evaluation that have not been validated (Gozu et al., 2007) 35 and base themselves on post-test only or single group pre-test/post-test self-reports of knowledge and attitudes acquired in the process (Haarmans, 2004). While there is some evidence that properly designed cultural competence training can change trainees attitudes (Curtis et al., 2007; Crosson et al., 2004; ), there is a lack of evidence substantiating that such training improves ‘patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups’ (Beach et al., 2005). (2) Attitude focus A second major limitation of cultural competence training discussed in the literature concerns the continuing overemphasis in a lot of cultural competence training designs on awareness-building aimed at attitude change. “The literature indicates that current diversity training practices begin and end with awareness building” Curtis et al., for instance conclude, in their (2007) review of diversity and cultural competence training literature between 2000 and 2005. 35 Curtis et al., (2007) for instance note, in the former respect, a significant discrepancy between the reported results of subjective (self-report) measures of attitude change, and the results of survey methods measuring attitude change using standardized instruments, which are much more mixed. 104
The Culture, Diversity and Equity Project: Literature Review There is a corresponding neglect or under-emphasis of skills-focused training interventions (Curtis et al., 2007; Engerbretso et al., 2008). Curtis et al., moreover, cite research findings that suggest “even if measurable attitudinal change does occur as a reported consequence of [such attitude-based] training, attitudinal change does not necessarily result in changed behaviour” (see also Armour, Bain, & Rubio, 2004; Bieschke et al., 2003; Tomlinson-Clarke 2000). (3) Stereotyping Another limitation associated with knowledge-based approaches to cultural competence training concerns the persistence of stereotyping teaching strategies that depict groups in static, homogeneous ways (Betancourt et al., 2005; Engerbretso et al., 2008). The failure to recognize the complexity of individual cultural identity and formation, can lead to misdiagnosis and culturally incompetent care. Frequently, such ‘categorical’ approaches to training focusing on the particular cultural norms of particular ethnic groups, moreover, fail to address and account for the cultural orientation of the dominant health care system and its providers (Engerbretson et al., 2008). (4) Lack of standards and criteria for assessment While cultural competence education for medical/healthcare professionals in training in universities and colleges has grown in sophistication and consistency as a result of the introduction of accreditation standards, continuing cultural competence education for practicing health care professionals has been described as “increasingly haphazard and varying in quality” (California Endowment, 2003). One of the major reasons for this is the lack of agreed upon standards and evaluative criteria by which to plan or assess cultural competence training for existing healthcare professionals (ibid.). (5) Training as substitute for organizational change A last salient limitation or critique of cultural competence training in the literature is the false sense of accomplishment this can bestow on organizations providing it. Cross et al.’s (1989) cultural competence continuum for assessing organizations is telling in this respect as it situates organizations at the pre-competence phase as frequently and inordinately focussing on training and diverse staff hiring, yet too often to the neglect of more fundamental and systemic changes in the way business is conducted in the organization. Cultural competence training – most of which tends to focus on improving individual staff attitudes, knowledge, and behaviour - is a necessary but insufficient condition (and certainly no substitute) for improving the cultural and linguistic appropriateness and accessibility of programs and services. 5.4. BEST PRACTICES & RECOMMENDATIONS Among the salient recommendations and best practices identified in this review of the cultural competence training literature are: • Evaluating - and properly designing evaluations (e.g. experimental pre/post-test designs using validated instruments) of - training programs for their impact on trainees behaviour as well as client health outcomes (Gozu et al., 2007; Curtis et al., 2007). • Developing greater (evidence-based) consensus on training standards and evaluative criteria for cultural competency training and skills assessment. This is a particularly important priority in the field of continuous education for existing health care professionals (OMH, 2001; Betancourt, 2005). • Focusing on skills versus solely attitudes and knowledge in training modules by employing a practiceoriented, skills-based approach to training that focuses on specific competencies and skills required to function culturally competently in a particular organizational setting (Engerbretso et al., 2008). Taking a systems approach to cultural competence training. A systems approach treats training as a “key component of a health care organization’s strategic approach to organizational performance”, and links it to the 105
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Appendix 1: Health Equity Literatur
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HEALTH EQUITY LITERATURE REVIEW INT
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